
Glass. 



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COPYRIGHT DEPOSIT 



PRACTICE OF MEDICINE — WHITTAKER 









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Pathogenic Micro-organisms 

See description on page vi. 



N 



THE 



THEORY AND PEACTICE 



OF 



MEDICINE 



PREPARED FOR 



STUDENTS AND PRACTITIONERS 



JAMES T. WHITTAKEE, M.D., LL.D. 

Professor of the Theory and Practice of Medicine in the Medical College of Ohio; Lecturer on 

Clinical Medicine at the Good Samaritan Hospital; Fellow of the College of Physicians 

of Philadelphia; Member of the Association of American Physicians, of 

the American Academy of Medicine, and of the American 

Medical Association 



WITH A CHR0M0-LITHOGRAPHIC PLATE AND THREE HUNDRED ENGRAVINGS 

WS8 1892 
NEW YORK Ns s^> WAS ^€ 



WILLIAM WOOD & COMPANY 

1893 



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Copyright by 
WILLIAM WOOD & COMPANY 

18 £3 



PRESS OF 

5TETT1NER, LAMBERT & CO., 

22, 24 & 26 READE ST., 

NEW YORK. 



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tmp96 028694 



THIS BOOK IS DEDICATED 

(by permission) 



EOBEET KOCH, 

MEDICAL PRIVY COUNCILLOR OF PRUSSIA: 

FOUNDER OF BACTERIOLOGY: WHOSE WORK IS MAKING A SCIENCE 

OF THE ART OF MEDICINE ; 

BY 

BIS FIRST AMERICAN STUDENT '; 



GEOEGE M. STERNBERG, 

SURGEON- GENERAL OF THE UNITED STATES ARMY: 
THE PIONEER IN THE STUDY OF PARASITISM IN THIS COUNTRY 

BY 

HIS FRIEND, 



THE AUTHOR. 



"As for the truth, it endureth and is 
always strong ; it liveth and conquereth 
for ever more." 



-Esdras I. iv. 38. 



Pilate saith unto him, What is truth f" 



-John xviii. 38. 



:i Appie del vero il dubbio." 

—Dante, Del Par ad i so, iv. 131. 



PREFACE. 



In the preparation of this book the most work has been put upon 
the infections, as the most frequent and dangerous, at the same time 
the most preventable, of all diseases ; and in the study of the infec- 
tions the most space has been devoted to cause and diagnosis, for 
the reason that a knowledge of the cause establishes prevention, and 
with the diagnosis develops treatment, except in so far as treatment 
must still remain wholly sj'mptomatic. Morbid anatomy meets here 
with but little consideration, and post-mortem revelations are men- 
tioned only when they may throw a clear light upon the nature and 
treatment of disease. The practitioner who looks up from the signs 
and lesions to the cause will entertain more hope of treatment : for 
the practice of medicine is now not so empirical as the symptoma- 
tologists claim, or so barren as the pathologists deplore. 

From this standpoint this book is prepared for the student and 
practitioner of medicine, but especially for the young physician who, 
with microscope and test tube, would fit himself for the higher 
places in his profession. 

With the most highly appreciated generosity, the Messrs. Win. 
Wood & Co., Lea Bros. & Co., and W. B. Saunders have per- 
mitted the author to select, condense, or make use of contributions 
prepared by him for works recently or just issued by them. These 
chapters (selections from which constitute perhaps one-twelfth of 
the present volume), in Wood's " Reference Handbook," Pepper's 
''System of Medicine,''" Hare's '"Therapeutics/" Pepper's "Ameri- 
can Text Book,'' contain accounts more full than may be found in 
an ordinary text book, whose chief merit must consist in the suc- 
cinct presentation of the latest facts. The fact that the proof was 
corrected at a watering place distant from a library will excuse the 
absence of proper credit from smj figures or statements where it 
may have been lost in press. 

A text book must necessarily be full of shortcomings. No one so 
fully appreciates the vast wealth of knowledge in internal pathology, 
accumulated through the ages, as he who attempts to encompass it 
in a book, or so keenly realizes his own poverty as he who attempts 
to add to the general sum the most inconsiderable mite. 

J. T. W. 

Cincinnati, Ohio, September 1st, 1893. 



PATHOGENIC MICKOOKGANISMS. 

Chiefly from Original Drawings by Koch and Loffler. 

EXPLANATION OF PLATE. 

Fig. 1. Lepra. — Fluid expressed from a nodule, stained with carbol-fuchsin, display- 
ing bacilli, free and enclosed in large, non-nucleated cells. 

Fig. 2. Malaria. — Plasmodium Malarias. Protozoa from drop of blood from finger 
pulp after a chill, stained with methylene blue, displaying large, nucleated white 
blood corpuscles, smaller non-nucleated red blood corpuscles, free and filled with 
protozoa; also free protozoa. 

Figs. 3, 4. Pymmia. — Streptococcus pyogenes and Staphylococcus pyogenes aureus. 

Fig. 5. Oonorrhcea. — Gonococcus, cover-glass preparation, stained with methylene 
blue; pus cells filled with gonococci. 

Fig. 6. Pneumonia. — Diplococcus of pneumonia (Frankel-Weichselbaum), stained 
by Gram's method; section of alveolus, displaying exudation of cells with diplo- 
cocci, alone and in chains, in and between the cells. 

Fig. 7. Charbon. — Milzbrand bacilli, gelatin stick culture; upper stratum fluidified, 
bacilli as whitish mass at bottom of fluid; displaying two large colonies with 
numerous radiating outshoots into the substance of the still solid gelatin. 

Fig. 8. CJiolera. — Stick culture of cholera spirillum in gelatin, four days old ; upper 
stratum exposed to air, fluidified to characteristic funnel shape ; spirilla in 
mass at bottom and in neck of funnel. 

Fig. 9. Typhoid Fever.— Gelatin stick culture of typhoid bacillus, displaying opales- 
cent, translucent surface. 

Fig. 10. Tuberculosis. — Pure culture of tubercle bacillus on surface of gelatin in 
inclined test tube, displaying dry, white scales, natural size. 

Fig. 11. Cholera. — Gelatin surface culture of cholera spirillum, x 80, displaying irregu- 
lar border and irregular " broken-glass" surface. The larger colonies, with more 
sunken border, lie nearer the surface of the gelatin. 

Fig. 12. Typhoid Fever. — Gelatin surface culture of typhoid bacillus, x 80, displaying 
dark- brown, sharply- defined border with finely granulated surface; sometimes 
showing concentric zones. 

Fig. 13. Glanders. — Bacillus mallei from spleen of field mouse, cover-glass prepa- 
ration, stained with methylene blue, displaying uncolored regions resembling 
spores. 

Fig. 14. Cholera. — Pure culture of cholera spirillum in bouillon, stained with fuch- 
sin, displaying "comma" bacilli, alone and united in spirals. 

Fig. 15. Typhoid Fever. — Pure culture of typhoid bacillus in gelatin, displaying short, 
thick rods as in tissues, and elongated structures in culture. 

Fig. 16. Tuberculosis. — Tubercle bacillus from sputum, double-stained with aniline- 
gentian- violet and Bismarck brown. 

Fig. 17. Dysentery. — Amcebre coli. 



TABLE OF COXTE'HTS. 



PART I. 
GENERAL DISEASES. 

INFECTIONS-PAEASITES. 

CHAPTER I. 

Ectozoa, 3 

Animal : Scabies — Pediculi, capitis, pubis, vestirnenti — Acarus folliculo- 
rum — Pulex — Pulex penetrans— Cimex — Mosquito, etc. Vegetable: Fa- 
vus— Herpes tonsurans, Eczema marginatum, Onychomycosis — Pityriasis 
versicolor, Madura Disease, Muscardine, Fly Fungus — Thrush— Lepto- 
thrix buccalis — Actinomycosis. 

CHAPTER II. 

Entozoa, 23 

Cysticercus cellulose — Taenia armata, saginata, lata — Taenia echinococ- 
cus — Multilocular Cysts — Round Worm — Threadworm — Whipworm — 
Anchylostoma — Trichina spiralis — Filaria, medinensis, sanguinis — Ele- 
phantiasis — Liver Fluke — Distoma Haematobium. 

CHAPTER III. 

Bacteria, 56 

Bacteria — Microprotein — Micrococci — Bacilli — Spirilla— Spores — Sapro- 
phytes— Parasites— Aerobes — Anaerobes — Coloration— Cultivation — Inocu- 
lation — Ptomaines— Toxines— Phagocytes — Antitoxiues— Protozoa — Rhi- 
zopods — Sporozoa— Infusoria — Plasmodium malarias. 

CHAPTER IV. 

Infectious Diseases, 68 

Diseases caused by Micrococci, Bacilli, Spirilla : Septicaemia — Pyaemia — 
Septico-pyaemia. Staphylococcus pyogenes aureus, albus, citreus, Micro- 
coccus pyogenes tenuis, Staphylococcus pyogenes : Erysipelas — An- 
thrax — Foot and Mouth Disease — Glanders— Hydrophobia — Tetanus — 
Pertussis— Influenza — Hay Fever— Pneumonia — Tuberculosis — Lepra — Sy- 
philis —Chancroid — Gonorrhoea. 



Vlll TABLE OF CONTENTS. 

CHAPTER V. 

Infectious Diseases — Continued, 186 

Mumps — Measles — Rubella — Scarlatina —Variola, Varioloid, Vaccination 
— Varicella— Diphtheria— Croup— Quinsy — Typhus, Relapsing, Typhoid 
Fever — Malaria — Yellow Fever — Cerebro-spinal Meningitis — Rheumatism 
— Dysentery — Asiatic Cholera— Cholera Morbus. 



PART II. 

DISEASES OF OKGANS. 

DISEASES OF THE ORGANS OF DIGESTION. 

CHAPTER I. 

Diseases of the Mouth, Fauces, and Pharynx, 349 

Syphilis — Stomatitis, catarrhalis, ulcerosa — Aphtha — Noma— Glossitis — 
Angina — Tonsillitis— Globus hystericus — Cancer of the (Esophagus — An- 
gina Ludovici — Retropharyngeal Abscess. 

CHAPTER II. 

Diseases of the Stomach, . . . 363 

Gastric Catarrh — Ulcer — Cancer — Gastrectasia— Gastralgia — Diagnosis, 
Diet, Treatment. 

CHAPTER III. 

Diseases of the Intestine, 397 

Intestinal Catarrh — Ulcer— Haemorrhage of the Bowels— Typhlitis, Peri- 
typhlitis, Paratyphlitis, Appendicitis— Occlusion — Cancer— Peritonitis. 

CHAPTER IV. 

Diseases of the Liver, . 439 

Icterus — Cholelithiasis — Abscess— Cirrhosis — Hypertrophic Cirrhosis- 
Simple Atrophy — Acute Yellow Atrophy — Weil's Disease— Hyperemia — 
Fatty Liver — Amyloid Liver— Cancer. 



DISEASES OF THE ORGANS OF RESPIRATION. 
CHAPTER V. 

Diseases of the Nose and Thr6at, . 478 

Acute and Chronic Catarrh— Syphilitic Catarrh — Neoplasms. 

Diseases of the Larynx, . . .481 

Catarrhal Laryngitis— (Edema of the Glottis— Perichondritis— Tuberculo- 
sis— Syphilis — Paralysis of the Larynx — Tumors. 



TABLE OF CONTENTS. IX 

CHAPTER VI. 
Diseases of the Lungs 489 

Bronchitis, Acute, Capillary, Chronic— Bronchorrkcea— Putrid Bronchi- 
tis— Fibrinous Bronchitis— Bronchiectasis— Asthma— Emphysema— Pneu- 
monia, Catarrhal, Hypostatic — (Edeina of the Lungs — Atelectasis — 
Drowning — Embolism, Hemorrhagic Infarction — Abscess— Gangrene — 
Syphilis — Cancer, Sarcoma, Echinococcus—Pneumonoconiosis— Pleu- 
risy — Empyema — Pneumothorax — Hydrothorax — Hematothorax — Peri- 
pleuritic Abscess — Subphrenic Abscess. 

DISEASES OF THE ORGANS OF CIRCULATION. 

CHAPTER VII. 

Diseases op the Heart, 554 

Pericarditis — Tuberculosis, Syphilis of the Pericardium— Hydroperi- 
cardium — Endocarditis — Sclerotic Endocarditis — Myocarditis — Heart 
Failure — Tuberculosis — Syphilis — Neoplasms— Neuroses — Palpitation — 
Angina Pectoris — Exophthalmic Goitre— Myxcedema. 

Diseases of the Blood Vessels, 590 

Arterio-sclerosis — Aneurism of the Aorta — Phlebitis, # 

CHAPTER VIII. 
Diseases of the Blood, 597 

Plethora — Hydremia — Lipemia — Uraemia — Choleinia — Blood Parasites — 
Anemia — Pernicious Anemia — Chlorosis — Leukemia — Pseudo-leukemia 
— The Hemorrhagic Diathesis — Hemoglobinemia — Purpura — Haemophi- 
lia — Scorbutus — Morbus Addisonii— Gout — Arthritis Deformans — Rachitis 
— Osteomalacia — Obesity. 

DISEASES OF THE GENITO-URINARY SYSTEM. 
CHAPTER IX. 

Diseases of the Kidney, . . 637 

History — Albuminuria — Casts— Dropsy— Uremia — Hypertrophy of the 
Heart — Hyperemia — Anemia — Acute Parenchymatous Nephritis — 
Chronic Parenchymatous Nephritis — Renal Cirrhosis — Amyloid Degenera- 
tion — Tuberculosis — Syphilis — Floating Kidney. 

CHAPTER X. 
Diseases of the Pelvis of the Kidney, Bladder, etc., .... 663 
Nephrolithiasis— Pyelitis— Hydronephrosis— Cystitis— Enuresis— Sperma- 
torrhoea— Impotence — Diabetes Mellitus — Diabetes Insipidus. 

DISEASES OF THE NERVOUS SYSTEM. 
CHAPTER XI. 

Diseases of the Nerves and Membranes, 685 

Neuralgia, Trigeminal, Occipital, Intercostal— Sciatica— Coccyodynia— 
Headache— Migraine— Gastralgia— Enteralgia— Neuralgia of the Sperm- 
atic Cord— Neuralgia of the Joints— Neuritis— Multiple Neuritis— Spasm— 
Myotony— Torticollis— Lumbago— Paralysis— Facial Paralysis— Meningitis 
—Pachymeningitis— Hypertrophic Cervical Pachymeningitis— Leptomenin- . 
gitis. 



X TABLE OF CONTENTS. 

CHAPTER XII. 

Diseases op the Spinal Cord, 707 

Myelitis — Locomotor Ataxia — Hereditary Ataxia — Lateral Sclerosis — Pro- 
gressive Muscular Atrophy — Infantile Paralysis— Bulbar Paralysis — Acute 
Ascending Paralysis— Spinal Haemorrhage— Syringomyelia — Acromegaly 
— Morvan's Disease — Raynaud's Disease — Brown-Sequard's Paralysis — 
Progressive Dystrophy — Pseudo-hypertrophy — Juvenile Dystrophy— He- 
reditary Atrophy — Facial Atrophy — Tetany. 

CHAPTER XIII. 
x 
Diseases of the Brain, 736 

Apoplexy — Epilepsy — Tumor — Abscess — Localization of Lesions — Hyste- 
ria — Hypochondriasis— Neurasthenia — Chorea — Paralysis Agitans — Multi- 
ple Sclerosis — Dementia Paralytica — Avocation Neuroses — Insolation — 
Congelation — Saturnism — Alcoholism — Delirium Tremens — Cocainism — 
Poisoning by Opium — Poisoning by Nicotine — Poisoning by Gases. 

Notes, 799 

Index, S07 






LIST OF ILLUSTRATIONS. 



FIG. PAGE 

Chromo lithograph of pathogenic micro-organisms, vi 

1. Female Acarus scabiei, dorsal surface, 4 

2. Acarus burrow, with ova, .5 

3. Pediculus capitis, male, 6 

4. Hair with agglutinated eggs and nits, 6 

5. Pediculus pubis, 7 

6. Pediculus vestimenti, 8 

7. Acarus folliculorum, 8 

8. Achorion Schonleinii from favus cup, 9 

9. Favus scutulum, 10 

10. Hair and root sheaths in favus, infiltrated with conidia and my celia, . .11 

11. Epidermis scale in herpes tonsurans, showing more mycelia than conidia, . 12 

12. Hair in herpes tonsurans, 13 

13. Onychomycosis, 13 

14. Microsporon furfur, 14 

15. Pityriasis; mycelia and conidia 15 

16. Mycoderma albicans, 15 

17. Transverse section of flake of coat of tongue after death in typhoid state, 

covered with mycoderma, 16 

18. Thrush fuigus, 17 

19. Leptothrix buccalis, 18 

20. Actinomyces, . . .19 

21. Actinomyces of the tongue, 19 

22. Taenia saginata, . . . . 24 

23. Segments of taenia in motion, 25 

24. Ova containing embryos of Taenia saginata, 25 

25. Calf's heart with measles of Taenia saginata, 25 

26. Cysticerci, . ' 25 

27. Measles in pork, 27 

28. Pork tapeworm, 27 

29. Head and neck of Taenia saginata, .28 

30. Head of Taenia solium within that of Taenia saginata, to show differences, . 28 

31. Head and neck of Taenia lata, 29 

32. Ova of fish tapeworm, 29 

33. Segments of taenia, ' . .31 

34. Taenia echinococcus, . . . 35 

35. Extended echinococcus with hooklets . . .35 

36. Echinococcus sacs in the liver of man, 35 

37. Echinococcus membrane with hooks, ' . .35 

38. Echinococcus multilocularis, 37 



Xll LIST OF ILLUSTRATIONS. 

FIG. PAGE 

39. Ascaris lumbricoides, 38 

49. Round worm, 39 

41. Oxyuris vermicularis, .42 

42. Oxyuris vermicularis, 42 

43. Whipworm, female and male, 44 

44. l-'ggs of entozoa, 44 

45. Anchylostomum duodenale, • . .45 

46. 47. Mature trichinae, .."_'.. • 46 

48. Young trichinae in muscle, 47 

49. Trichina encapsulated in muscle, ......... 48 

50. Calcified relics, . . .48 

51. Young trichina liberated from capsule, . . . ..'.■'• - .48 

52. Encapsulated trichina, 48 

53. Trichina in muscle, ... . . . . .50 

54. Guinea worm, . ..-.'•-. .52 

55. Filaria sanguinis, ... .53 

56. Filarise in blood vessels, 53 

57. Elephantiasis cruris lymphangiectatica • .53 

58. Liver fluke, 54 

59. Distoma hsematobium with ova, 55 

60. Bacilli stained to show vibratile cilia and fiagella, . r . . . .57 

61. Streptococcus, . . ... 58 

62. Spirochetes of relapsing fever, . . .. . . . . . .58 

63. Sarcina?, 58 

64. Yeast plant, 58 

65. Bacillus pneumoniae with gelatinous envelope, .58 

66. Bacilli tuberculosis, showing spores, . . . . . . . . 59 

67. Bacillus Havaniensis, 62 

68. Scale surface culture (serum) of tubercle bacillus, . .... .62 

69. Nail stick culture (gelatin) of pneumococcus, 62 

70. Trichomonas intestinalis, . . ., . , . . . .65 

71. Naked amoeba? coli, . . ...... . . . . .65 

72. Cercomonas intestinalis, . . . . . . ., ? . ..65 

73. Plasmodium malariaa, , . . . . . .66 

74. Coccidia from the human liver, .66 

75. Scirrhus of the breast, , . . . . . . . ... .67 

76. Pus from an acute abscess, . . . . . . . . . .69 

77. Septic infection of pectoral muscle after a " post-mortem " wound of the 

hand,. .............. 69 

78. Temperature in a fatal case of sepsis, >j. .70 

79. Erysipelas cocci in the cutis, . . . . . ... . . 73 

80. Streptococcus erysipelatis, . .. . . ... . . . 74 

81. Temperature in severe facial erysipelas, . . . . . . . 77 

82. Anthrax bacillus, with and without spores, from spleen, . . . .82 

83. The anthrax bacillus in the blood, . . . . .:■'.. .85 

84. The bacillus of glanders, . . , ,. .. ... . . ,91 

85. Farcy buds in the skin, . . . . . . . . . .92 

86. Tubercular glanders in the nose, . . . ,.-■ ... . . . 93 

87. Discharging cicatrices in the nose,. . . . -. . . . .91 

88. Bacillus of tetanus, . . , ....... . . .107 

89. Pneumococcus of Friedlander ; oval cells with gelatinous envelope, . . 126 



LIST OP ILLUSTRATIONS. Xlll 

FIG. PAGE 

90. Pneumococcus of Friedlander ; stick culture in gelatin, .... 126 

91. Diplococcus pneumoniae, 127 

92. Diplococci from sputum, acute pneumonia, early stage, . . . . 128 

93. Diplococcus of pneumonia in sputum, much more highly magnified, . 128 

94. Temperature chart ; fibrinous pneumonia, adult, 129 

95. Temperature chart ; fibrinous pneumonia in child, 129 

96. Section of alveolus of lung in croupous pneumonia, filled with exudate 

consisting of fibrin, with desquamated epithelium and red and white 
blood corpuscles (Delafield and Prudden), . . . . . .131 

97. Diplococcus of pneumonia in sputum, 135 

98. Tubercle bacilli — sputum, 138 

99. Tubercle bacilli with spores, in sputum . 139 

100. Tubercle bacilli in sputum, 140 

101. Tubercle bacilli in sputum, . . 140 

102. Tubercle bacilli in sputum, 141 

103. Colonies of tubercle bacillus in scales on surface of blood serum, six weeks 

old, . . . - 141 

104. Hectic {i.e. , septic) fever in tuberculosis, . . . . . . 147 

105. Phthisical thorax in a girl eighteen years old, 147 

106. Tubercular ulcer of ileum, 148 

107. Tubercular ulcers in the larynx and trachea, seen on vertical section, . 149 

108. Shred of elastic tissue in sputum, 151 

109. Elastic tissue with epithelium and bacteria, .151 

110. Bacillus tuberculosis in urine, 164 

111. Tuberculous caries (stiffness) of cervical vertebra?, 165 

112. Tuberculous caries (gibbus) of dorsal vertebras, 165 

113. Leontiasis leprosa, 168 

114. Mutilating leprosy, 169 

115. Lustgarten's bacillus of syphilis, 171 

116,117,118. Teeth in hereditary syphilis, . . . . . . .171 

119. Syphilitic roseola with malformation of teeth, 172 

120. Syphilis of the larynx with great deformity, 173 

121. Tubercular syphiloderm of face, . . . . . . . .174 

122. Syphilitic necrosis of cranium, 175 

123. Syphilitic endarteritis 176 

124. Gonococcus, '. 180 

125. Gonococcus in pus cells, . . . 180 

126. Non-specific bacteria, streptococcus and staphylococcus, found in urine, . 183 

127. Cystin plates, gonorrheal thread, spermatozoids, 184 

128. Temperature in simple measles, 193 

129. Contrast between the fever of scarlatina and that of measles, . . . 194 

130. Mild scarlatina, . . .205 

131. Protracted scarlatina, . . . . 205 

132. Fatal scarlatina, . . ... .205 

133. Pock of small-pox, . . . . . . . . . . .221 

134. Temperature chart in variola, showing secondary fever, . . . . 222 

135. Mortality from small-pox in Boston, 236 

136. Deaths from small-pox in Berlin and Yienna, . . . . . . 237 

137. Strokes and cross-strokes for vaccination, . . . . . . 239 

138. Bone point for vaccine virus, . . 239 

139. Bacillus diphtherias from blood serum, • . . . . .... 246 



XIV LIST OF ILLUSTRATIONS. 

FIG. PAGE 

140. Streptococcus and staphylococcus from exudate, . . . . 247 

141. Temperature chart in adynamic petechial typhus fever, . . ' . . 262 

142. Temperature chart in ordinary typhus, 263 

143. Temperature chart in typhus fever, 263 

144. Temperature chart in typhus fever, 264 

145. Temperature chart in typhus fever, 264 

146. Spirilla of relapsing fever in the blood - . . 267 

147. Temperature chart, relapsing fever, . . 268 

148. Typhoid bacillus. Pure culture, 269 

149. Typhoid bacilli in the wall of the intestine, 210 

450. Typhoid bacilli from section of spleen, 270 

151. Typhoid bacilli in mucous membrane of small intestine (child), . . 270 

152. Typical temperature curve in severe typhoid fever, 271 

153a. Typhoid fever with recrudescence. Primary fever, .... 277 

1535. Typhoid fever with relapse after twenty-four days' interval. Relapse, . 278 

154. Typhoid fever with recrudescence, 278 

155. Temperature curve in man after injection of blood from patient affected 

with malarial (quartan) fever, 288 

156. Plasmodium malarice, 288 

157. Quotidian fever, 291 

158. Tertian fever, 291 

159. Quartan fever, 291 

160. Temperature chart, yellow fever; mild case, 296 

161. Temperature chart, yellow fever; typical severe case, .... 297 

162. Temperature chart, yellow fever; protracted case, 298 

163. Liver cells in yellow fever with necrotic masses in and between the liver 

cells, 299 

164. Streptococcus from vomit (not black) of yellow fever. .... 299 

165. Extreme opisthotonos, 303 

166. Hyperpyrexia of acute rheumatism, 317 

167. Torticollis, 322 

168. Descending colon with sloughing pseudo-membrane. .... 327 

169. Descending colon with oval ulcers, 329 

170. Cicatrices of diphtheritic ulcers in the colon, 334 

171. Comma bacillus of cholera, pure culture 337 

172. Mould fungi, etc. , from mouth, . . . 351 

173. The tongue coated white,' moist. Section from case of granular kidney, . 355 

174. The tongue denuded, red, and dry (raw beef tongue). Section from cafe 

of peritonitis, 355 

175. Pharyngo- nasal catarrh. Physiognomy before removal of adenoid tissue, 357 

176. Pharyngo-nasal catarrh. Physiognomy after removal of adenoid tissue, . 357 

177. Action of the digestive juices, 366 

178. r l he soft stomach tube with openings at the end and side, and with re- 

ceiving glass funnel, 367 

179. Partially digested matter from the stomach, ...... 367 

180. Irrigation of the stomach . 370 

181. Discharge by siphonage, 370 

182. Microscopic appearance of section of scirrhus carcinoma, . . . .381 

183. Hasmin crystals obtained by Teichmann's test, .;.... 382 

184. Protozoa in the fasces, 400 

185. Fasces under the microscope, 400 



LIST OF ILLUSTRATIONS. XV 

FIG. PAOE 

186. Tubercular ulcer of ileum, 405 

187. Typhlitis. Ulceration of the vermiform appendix, 419 

18S. Distended ductus choledochus, 444 

189. Dilated bile ducts with thickened walls under pressure from cancer of pan- 

creas, 444 

190. Two large gall stones from the gall bladder articulated by smooth surfaces, 447 

191. Faceted gall stones, natural size, 447 

193. Section of compound gall stone with concentric laminae and with nucleus 

formed by a smaller gall stone, 448 

193. Section of gall stone with concentric nucleus; concentric laminae only at 

one end, 448 

194. Section of cholesterin stone after removal of cbolesterin, .... 449 

195. Cirrhosis hepatis (hobnail liver), 463 

196. Apparent enlargement of the liver, the result of tight lacing, . . . 472 

197. Cancer of the liver, 477 

198. Nasal mucus, 478 

199. Adenoid tissue at vault of pharynx 479 

200. Posterior nares in the rhinoscope, 479 

2.01. Normal larynx and trachea to bifurcation of bronchi, . . . .482 

202. (Edema of the glottis, 485 

203. Advanced tuberculosis of the larynx, 486 

204. Papilloma of the larynx, 486 

205. Fibroid tumor of the larynx, 486 

206. Cancer of the larynx, 486 

207. Normal larynx. Position of cords in deep inspiration, .... 487 

208. Normal larynx. Position of cords in phonation, 487 

209. Paralysis of the arytenoid in phonation 487 

210. Paralysis of both thyro-arytenoids in phonation, 487 

211. Paralysis of the arytenoid and both thyro-arytenoids in phonation, . .487 

212. Paralysis of left recurrent in respiration, 487 

213. Paralysis of left recurrent in phonation, 487 

214. Paralysis of right posterior crico-arytenoid in respiration, . . . 487 

215. Paralysis of both posterior crico-arytenoids in respiration, . . .487 

216. Paralysis of both recurrents— cadaver, 487 

217. Koch's syringe, . . " 491 

218. Fibrinous bronchitis, ..." 498 

219. Casts of the bronchial tubes expectorated in fibrinous bronchitis, . . 498 

220. Asthma crystals, 510 

221. Curschmann's spirals in the sputum of asthma, 510 

222. Spirals with crystals in sputum of asthma, 511 

223. Emphysema pulmonum, • . .519 

224. Cellular pneumonia, 523 

225. (Edema pulmonum. Desquamated epithelium enclosing particles of 

coal, 528 

226. Marshall Hall's method of artificial respiration, 532 

227. Sylvester's method, .533 

228. Sylvester's method, 533 

229. Howard's method, . .534 

230. Mould fungi from sputum of abscess of lungs, 536 

231. Sputum from abscess of lungs, showing elastic tissue, fat crystals, phos- 

phates, epithelium, pigment matter, pus cells, and bacteria, . . . 537 



XVI LIST OF ILLUSTRATIONS. 

FIG. PAGE 

232. Micrococcus pneumoniae crouposae, showing capsule from exudate in 

pleural cavity of inoculated rabbit, 543 

233. Limited expansion of chest on left side, 544 

234. Tyrosin in needle-shaped crystals arranged in bundles- and stellate 

groups, ; 548 

235. Cor villosum. Fibrinous pericarditis, 555 

236. Pericardial effusion with displacement downward of the liver, . . . 560 

237. Endocarditis at and about the aortic valves, with ulceration, perforation of 

valves, and thrombi, 565 

238. Sphygmographic tracing of normal pulse curve, 570 

^239. Pulse curve of mitral regurgitation with perfect compensation, . . . 570 

240. Mitral regurgitation with systolic murmur at the apex, .... 571 

241. Mitral stenosis with diastolic — i.e., presystolic — bruit at the apex, . .571 

242. Aortic regurgitation with diastolic bruit at second right interspace, . . 572 

243. Aortic stenosis with systolic bruit at second right interspace, . . . 572 

244. Pulse curve in mitral stenosis with broken compensation ; feeble ascent, 

feeble force, 573 

245. Hypertrophy of the left ventricle from insufficiency and stenosis of the 

aortic valves, 574 

246. Pulse curve in aortic regurgitation, 574 

247. Pulse curve in aortic stenosis, . . 575 

248. Topography of the heart. Mechanical relation of the heart and abdo- 

minal aorta to the stomach and contiguous viscera, .... 583 

249. Exophthalmic goitre, 587 

250. Exophthalmic goitre; enlarged thyroid and prominent eyes, . . . 588 

251. Exophthalmic goitre. Defective descent of upper lid in looking down, . 588 

252. Aneurism of femoral artery, . 593 

253. Aneurisms of the hypogastric artery, 593 

254. Aneurism of the aorta, 594 

255. Section of aneurism filled with clot, surrounded by dense layers of con- 

nective (fibrous) tissue, 595 

256. Obliteration of right femoral vein, showing remains of a thrombosis three 

years before death 596 

257. Poikilocythsemia, 600 

258. Pernicious anaemia, 605 

259. The blood in leukaemia, showing the disproportion of the white and red 

corpuscles, . . . . 609 

260. Hypertrophy of spleen in lienal lymphatic leukaemia, .... 610 

261. Gouty fingers 620 

262. Tophi in the joints and tendons, .621 

263. Arthritis deformans. Section of cartilage of head of femur, . . . 626 

264. Deformities of rickets, 630 

265. Casts of the urinary tubules in nephritis, 645 

266. Retinitis albuminurica with irregularly scattered white patches, . . 648 

267. Epithelium in urine of nephritis, . 649 

268. Chronic nephritis; epithelial and mixed casts, 650 

269. Topography of the kidney from behind, in relation to thoracic and ab- 

dominal viscera, 661 

270. Crystals of oxalate of lime, 664 

271. Mulberry-shaped red blood corpuscles in urinary sediment in haematuria, . 665 

272. Epithelial cells from mucous membrane of renal pelvis, .... 668 



LIST OF ILLUSTRATIONS. 



XV 11 



of the mucous 



membrane an 



columns of the 



cord. 



FIG. 

273. Urinary sediment in acute pyelitis, 

274. Stone causing hydronephrosis, 

275. Cystitis with gangrene and separation 

of the muscular coat, 

276. Multiple (alcoholic) neuritis, . 

277. Spasm of the trapezius, 

278. Facial paralysis, . 

279. Facial paralysis, . 

280. Beginning sclerotic patches, . 

281. Knee jerk after tap on patellar tendon, 
283. Tabes : perforating ulcer of the foot, 

283. Scleroses on cross-section of the lateral 

284. Posture of healthy child, 

285. Posture of infantile paralysis, 

286. Bulbar paralysis, . 

287. Pseudo-hypertrophic paralysis ; big calves of legs 

288. Pseudo-hypertrophic paralysis ; attempt to rise from floor, 

289. Pseudo-hypertrophic paralysis ; patient "climbing up his thig 

290. Forms of hemiplegia, 

291. Epilepsy, 

292. Tubercular tumor of middle lobe of cerebellum, 

293. Gliomata of left hemisphere, .... 

294. Cerebral localizations. Outside view, 

295. Localizations in the cerebrum. Inside view (Dana), 

296. Chorea magna, . . . . . 

297. Hysterical contracture of right leg and foot, 

298. Position of the hand in paralysis agitans, 

299. Attitude and gait in paralysis agitans, 

300. Duchenne's apparatus for relief of writer's cramp, 



d par 



hs. 



PAGE 

668 
670 

671 
691 
692 

694 
695 
712 
714 
715 
717 
724 
7 -J 4 
726 
732 
733 
733 
740 
746 
750 
751 
755 
756 
759 
760 
770 
771 
780 



PART I. 
GENERAL DISEASES 



" . . . For it is also thus in nature, 
the greatest balsams do lie enveloped in 
the body of most powerful corrosives ; I 
say moreover, and I ground upon expe- 
rience, that jjoisons contain within them- 
selves their own antidote and that which 
preserves them from the venom of them- 
selves, without which they were not dele- 
terious to others only, but to themselves 
also." 

— Thomas Brown, M.D., Reh'gio Medici. 



IXFECTIOXS-PAEASITES. 



OHAPTEE I. 



Most of the diseases of plants are produced by parasites. This 
fact, like the discovery of the cell structure in histology, has finally 
been brought to bear upon the diseases of man (pathology) and other 
animals, with the discovery in most cases of the same cause. Thus, 
it has been ascertained that diseases come, for the most part, from 
without, and not from within. 

The parasites of man are both animal and vegetable. Larger 
parasites lodge upon the surface — Ectozoa ; or through the food or 
drink reach the interior of the body — Entozoa. The ectozoa produce 
many of the diseases of the skin : entozoa are worms in the intestinal 
canal. 

Most of the vegetable parasites are so minute as to be microscopic. 
They are known as microbes or micro-organisms. They reach the 
recesses of the body by way of the mucous membranes or by inocu- 
lation of the skin. They multiply in the interior of the body to pro- 
duce symptoms, both by their presence and their products (toxines), 
and cause the group of diseases distinguished as the infections. 

Pathogenic micro-organisms are known. 1, by their morphology — 
that is, their size, shape, and general appearance ; 2, by their chemical 
affinities, as shown in their reactions to coloring matter ; 3, by their 
preference of soil in cultivation experiments, and the manner in 
which they grow in the soil ; 4, by the effect produced by their intro- 
duction into the bodies of various animals. 

The mass of micro-organisms belongs to the vegetable kingdom, 
to the subdivision cryptogamia, which forms neither flowers nor 
.seed, but reproduces itself by spores. Pathogenic micro-organisms 
ma}' be divided into : 

1. Fungi, or moulds. 

2. Ferments, or yeast plants. 

3. Bacteria, or schizomycetes. 
-±. Protozoa. 

The fungi include the various vegetable growths, often of such 
magnitude as to be visible to the naked eye, which cause many 



ECTOZOA — ANIMAL. 



skin diseases, and sometimes, by metastasis, as in the case of the 
actinomyces, affection of the internal organs. Yeast plants produce 
the various, chiefly the alcoholic, fermentations. Bacteria cause 
most infectious diseases. Protozoa certainly produce malaria and 
probably cause cancer. 



ECTOZOA. 



ANIMAL. 

Scabies (scurf; itch). — An eczema produced partly by the itch 
insect ( Acarus scabiei) itself, but chiefly by scratching in relief of the 
itch the insect causes. 

The disease has been always known, is alluded to in the Bible, 
and was formerly regarded as a constitutional (blood) malady, the 
cure of which might entail worse evils. 

The Acarus scabiei has a hard, crab-like body with thorny exterior; 
stiff hairs protrude from its borders. The head has strong jaws, 
which work like scissors and are fixed with teeth. Respiration is 
wholly cutaneous. The animal is bisexual. The female is oval- 
shaped, broader than long, 0.35x0.23 mm., white or gray ; the male 

smaller, 0.25 X 0.15 mm., brown or yel- 
low. Each has two pairs of extremities in 
front and behind, the first pair provided 
with suckers, a hinder pair in the male 
with fasteners. 

The male lives in slight excavations 
which he makes in the surface of the skin; 
the female bores for herself lightly curved 
burrows or canals, three centimetres long, 
in the course of which, as she advances, 
she deposits eggs, one or two per day. 
The young acari shed the skin three or 
four times at intervals of six days ; first 
in fourteen to seventeen days, to appear 
after the first moult with eight legs — hav- 
ing had but six hitherto — and after the third with mature sexual 
organs. 

The insect seeks naturally regions where the epidermis is thin 
and the deeper layers succulent, as the front of the wrist, sides of 
the fingers, space between the fingers, front of the axilla, flexure of 
the elbow, penis, nipple, etc. The face is spared except in bad cases, 
and in sucklings who may be infected by nurses. So, too, the dis- 
ease may be carried, by scratching, to unwonted seats, even to the 
hairy scalp. 




Fig. 1.— Female Acarus scabiei 
dorsal surface. 



ECTOZOA — ANIMAL. 

Scratching develops eczema, which is sometimes obstinate and 
extensive, and may require treatment after destruction of the cause 
of the disease. 

The lesion is that form of superficial irritation which shows itself 
in itch ing, and which may vary in every degree of intensity from 
annoyance to torture, according to the extent of the disease and sen- 
sitiveness of the individual. It is usually tcorse at night and may 
exhaust the strength through insomnia. 

The diagnosis rests upon, 1, the itch — the situation of the lesion; 
2, the character and course of the canals — curved lines colored with 
freces and studded with salient points ineffaceable on washing ; 3, the 
demonstration of the insect itself — a white granule at the end of a 
canal, which, with a little practice, may be lifted out under a lens on 
the point of a knife or a pin. 



■~ :r J ::'i .'fey A ■ ■■» ^*s^ 



mm) 

Fig. 2.— Acarus burrow, with ova. 

Treatment calls for the destruction of the parasite and all its 
progeny — usually an easy task — and in aggravated cases applica- 
tions in relief of the eczema. 

There is much choice of remedy; as a rule, mild means are the 
best. One of the following ointments should be thoroughly rubbed 
into the skin : 

1 J} Balsam i Peruviani, 

Styracis liquids aa 5 i. 

M. 

2 ty Florum sulphuris, 

Olei rusci , .aa 3 ij. 

Cretae preparatae gr. xv. 

Saponis viridis, 

Axungise , , aa \ ii. 

M. 

3? ^ naphthol z ss. 

Saponis viridis = iss. 

Cretae preparatae 3 ij. 

Axungise |nij. 



ECTOZOA — ANIMAL. 



4. A more elegant but more expensive preparation : 

$ Lactis sulphuris 1 ij. 

Potassii carbonatis 3 vi. 

Olei lavandulce, 

Olei caryophylli aa gtt. x. 

Axungise q. s. 

Ft. unguentum. 
Recipes No. 2 and 3 are better than No. 1. No. 3 is the best, be- 
cause it irritates less and soils least. In all cases a good quantity 
must be thoroughly rubbed into the affected parts. Woollen cloth- 
ing should be worn, that the surface be not robbed by absorption. If 
there is still itching the inunction must be repeated on the following 
day. Bath after several days. The cure of the scabies is now com- 
plete. Any eczema left will disappear under diachylon ointment. 
Bathing, as it aggravates eczema, should be avoided for four or 
five days, or until the skin under the ointments dries 
and desquamates. Finally, after bathing, the skin 
may be anointed with vaseline or cocoa butter. 

Pediculus Capitis (head louse). — An elongated, 
hard body, 2 x 1 mm. , which cracks between the fin- 
ger nails, with six feet provided with claws for climb- 
ing and clutching hairs. The female, which greatly 
— Pediculus outnumbers the male, glues her eggs to hairs by a 
layer of chitin, commencing at the head end of the 
hair and depositing eggs upward, as many as fifty in successive layers, 
so that the duration of infection may be determined, 
on inspection with a lens, by the situation of the eggs 
or young (nits). The young escape in three to eight 
days, and become mature in eighteen to twenty days. 
A single female may give birth within six weeks to 
five thousand young. 

The irritation caused by pediculi causes eczema 
through scratching ; and sts such regions are avoided 
in combing the head, they offer quiet retreat for multi- 
plication of the parasite and aggravation of the eczema. 
Continued neglect may thus lead to suppuration and 
agglutination of the hair into a foul, offensive mass or 
cap, the plica polonica. 

The insect is strictly confined to the hair of the 
head, but the resultant eczema may extend to the neck 
or face, or in bad cases lead to lymphangitis and swell- 
ing of the neighboring glands. 




capitis, male. 



Fig. 



-Hair with 



Cases of light infection are best treated by frequent agglutinated eggs. 



and nits. 



use of the fine-tooth comb and thorough ablution with 

soap. More extensive infection calls for a parasiticide, as a mixture 




ECTOZOA — ANIMAL. ( 

of equal parts of petroleum and balsam of Peru, which may be most 
thoroughly applied after cutting the hair short. The worst cases 
require more thorough saturation, as by the application and wear- 
ing, after inunction, of a flannel cap soaked in the same mixture 
made thinner by the addition of one-fourth part olive or cod-liver 
oil. Any fixed or volatile oil kills all kinds of lice (Leidy). The 
eggs and nits are afterward dislodged with saturated solutions of 
soda. Crusts are best softened with cod-liver oil. The eczema dis- 
appears with destruction of its cause. 

Pediculus Pubis (morpio; crab louse) finds its habitat on any 
hairy surface except the head, but is especially at home at the pubes, 
whence it is derived in sexual congress, and where it may be seen on 
close inspection as a small brown speck near 
the skin. It has the same general construc- 
tion as the Pediculus capitis, and the eggs 
are fastened to the hair, only close to the root, 
by the same chitin. The insect is effectually 
destroyed by mercury, best in the form of the 
white precipitate ointment. Two applica- 
tions of the size of the end of the little finger 
will always suffice to relieve the itching, ec- 
zema, or other effect, with the eradication of FlG " 5 - Pediculus P* bis - 
the cause. When mercury itself produces eczema or is contra-indi- 
cated from any cause, it may be substituted by naphthol with olive 
oil 1 : 10, or creolin 1 : 50. The remedy should be applied with cotton 
at night, and the application should be repeated on the following 
night, whereupon on the next morning it may be washed off with 
soap. To destroj T the young of subsequent growth, the application 
should be repeated at the end of one and two weeks. 

The most potent preparation for permanent cure — i.e., to destroy 
nits and eggs — is (Saalfeld) : 

Y P Hydrargyri bickloridi gr. x. 

Aceti communis § viii. 

M. S. Apply morning and evening for three days. 

Pediculus Vestimenti (body louse; clothes louse). — The largest 
of all the lice, 3-5 X 1-2 mm. It has the same general construction as 
the species above described, but lives in the clothes, and leaves the 
folds and creases, in which it lies secreted, to suck blood from the body 
as food. The irritation thus produced is intensely aggravated by 
scratching, so that the skin is torn by the nails and the surface is 
literally lacerated in every direction. Urticaria, excoriations, ec- 
zemata, pustules, furuncles, and actual ulcers may form in these 
regions. Parts of the body which suffer most are surfaces of closest 



ECTOZOA — ANIMAL. 




Fig. 6.— Pediculus 
vestimenti. 



contact with the clothes, as at the back of the neck and shoulders, 
sacrum, nates, hips, etc. • or regions of friction, as at the ivaist, 
wrist, line of the garter, etc. Continued irritation at these places 
leads to deposit of pigment, so that the affected sur- 
face may be deeply discolored. Infection is most ex- 
tensive in the class of peripatetic pilgrims commonly 
known as tramps, but is not infrequently seen in the 
higher classes as accidentally contracted in hotels, 
sleeping cars, ship cabins, etc. Moreover, exterior 
and interior do not always correspond. Undercloth- 
ing may be worn so long as to become a good breed- 
ing place after the slightest infection ; the clothing 
may be clean and the bed foul, etc. 

Treatment, to be effective, must be radical. The 
clothes, bedding, etc. , must be burned, boiled, steamed, 
or subjected to dry heat at 212° F. for twenty-four to forty-eight 
hours, or, when this is not practicable, saturated for hours in a solu- 
tion of sublimate 1 : 1000, or in crude petroleum. The surface irri- 
tation disappears with destruction of the cause. 

Acarus Folliculorum, an elongated, 0.08x0.02 mm., worm- 
like body, with mandibles and four pairs of extremities on the upper 
third of the body, is found in the secretion of the oil 
and hair glands, especially of the nose, temples, cheeks, 
external ear, etc., and rendered visible under the lens 
after expression of the contents of the gland by the fin- 
ger nails. These contents, of cheesy consistence, often 
with a top of black coal dust, flattened out under an 
object glass are seen to iD elude, for the most part none 
at all, but at times one, or exceptionally more — in re- 
corded cases as many as twenty — acari. The animal 
always lies head downward, and seems to be perfectly 
innocuous to man, though allied species do damage to 
the skin in lower animals. 

Pulex (the common flea) in its bite produces 
petechise with hypersemic areola, which fades on pres- 
sure and soon disappears altogether, while the petechise 
persist for several days. The flea bites usually covered fomiuiorum' 
surfaces in light contact with the clothes, as the back, 
chest, thighs, etc. Confusion with petechial eruption is avoided by 
observance of the region affected — the legs in purpura, the lower 
abdomen in variola, the upper abdomen in typhoid fever, etc. The 
central blood point of the fresh flea bite, and the dark -brown or black 
specks which mark the deposit of fseces, suffice for diagnosis. 

Pulex penetrans (the sand flea) is found along the coast 



Fig. 7.— Acarus 



ECTOZOA — VEGETABLE. 9 

regions. The female penetrates the surface to suck blood and leave, 
in the course of three or four days, more severe inflammation of the 
skin. Erysipelas, lymphangitis, ulceration, gangrene, even tetanus, 
have been thus introduced. 

Cimex lectularius (the bedbug) makes distinctions, in that 
it selects certain individuals and spares others. It produces in sen- 
sitive subjects, especially infants, itching urticaria, eczema, and, in 
consequence of scratching, more or less extensive incrustation. The 
insect makes its excursions in search of food at night only, and 
attacks more especially exposed surfaces — face, neck, and arms. 
These points suffice for diagnosis. 

Mosquitoes, Wasps, Bees, Horxets, or other Flies, and 
other insects, may produce lesions of the skin by bites, by the de- 
posit of eggs (maggots) in wounds, and, in the case of wasps and 
bees, by the insertion of poisonous matter. The history makes the 
diagnosis. The writer once failed to get a diagnosis from a class of 
students in the case of a patient semi-comatose with typhoid fever, 
one-half of whose face was thickly studded with papules while the 
other half was wholly free, the studded half having become exposed 
in the night from under the mosquito bar. 

The application of dilute liquor animonise 1 : 10, alcohol, or 
water with the addition of a few drops of carbolic acid or of creolin 
(one or two per cent), allays the irritation and neutralizes the poison 
of the bite. 



the 



VEGETABLE — DERMATOMYCOSES. 

Favus (honeycomb) ; tinea favosa. — An affection, chiefly of 
hairy scalp, produced by the growth of a mould 
fungus named by Remak in honor of Schonlein, 
its discoverer (1839), the Achorion Schonleinh. 
The disease begins as a papule penetrated by a 
hair. The papules grow gradually to the size 
of a ten-cent piece, flattening and sinking in the 
centre to form the characteristic saucer-shaped 
masses, scales, or cusps of sulphur-yellow color, 
the so-called scutula (dish). Crushed between 
the fingers the scales crumble, to emit a peculiar 
musty odor. Particles placed under the micro- 
scope show, with epidermis scales, hair frag- 
ments, detritus, etc., a wilderness of threads 
(mycelia) and spores (conidia), the cause of the 
disease. 

In the course of time the favus crusts co- 
alesce to form a more uniform mass : the invaded hairs lose their 




Fig 8.— Achorion Schon- 
leinii from favus cup (Ka- 
posi). 



10 ECTOZOA — VEGETABLE. 

lustre, appear as if powdered, become fragile, and are easily broken 
off or detached ; in bad cases, where the papilla is attacked, they 
may be permanently destroyed. The surface, which is now con- 
verted into a mortar-like, dirty yellow mass (honeycomb), presents an 
appearance offensive to both sight and smell. Crusts, which were 
before so adherent as to be detached with hemorrhage, now des- 
quamate continuously and the color gradually changes to gray or 
brown. 

The disease may in exceptional cases attack uncovered surfaces, 
and in still rarer cases invade the nails (onychomycosis favosa), which 
then show the same sulphur-yellow deposits with degeneration and 
detachment of nail substance. The characteristic elements of the- 




Fig. 9. — Favus scutulum : a, free border ; 6, corneal layer ; c, d, mycelia ; e, conidia; /, epithe- 
lium: y, papilla; h, cell infiltrate at base of scutulum; i, cutis (Neumann). 

growth have been observed once (Kundrat, Kaposi) in matter voided 
from the stomach. 

The disease is common to many domestic animals, especially to 
mice, rats, and cats, from the last of which it may be contracted, 
though infection usually comes from an affected bedfellow or from 
use of the same comb. It is not eminently contagious and may re- 
main confined to one child in a family in close contact with others 
for years. 

The diagnosis rests upon the form of the favus crusts, the yel- 
loiv color, the odor like that of mice, the destruction of the hair; 
more positively upon the presence of the parasite, which is best dis- 
played by the addition of a few drops of liquor potassse and examina- 
tion with glycerin. The diagnosis has been made easy since the dis- 
covery byNeisser that a favus crust touched ivith alcohol is stained. 



ECTOZOA — VEGETABLE. 



11 



a deep yellow, a change which does not occur in crusts of eczema'or 
other simulating affections. 

Treatment.— -The crusts must be softened with oils, that a parasi- 
ticide may be brought to bear directly upon the cause ofjthe disease. 







Fjg. 10 —Hair and root sheaths in favus, infiltrated with coaidia and mycelia. 



In uncovered places saturation with cod-liver oil over night, and the 
subsequent application of carbolic acid, naphthol, resorcin, thymol, 
or sublimate, according to the following formula?, suffice to control 
the disease. The disease is much more obstinate on hairy surfaces/ 
and successful treatment demands epilation. After softening bv 



12 ECTOZOA— VEGETABLE. 

saturation over night with cod-liver oil under a flannel cap, the head 
should be thoroughly washed with soap liniment, dried, and all loose 
hairs extracted. Thereupon one of the following preparations must 
be rubbed into the scalp with a stiff brush, whereby it is not neces- 
sary to give pain : 

1 R Acidi carbolici 3 ss. 

Olei olivse . I iv. 

M. 

2 R Resorciu 3 i. 

Unguenti petrolati ^iv. 

M. 

3 R Thymol 3 i. 

Chloroform § ij. 

Olei olivre | iv. 

M. 

4 R Unguenti hydrargyri ammoniati 3 ij. 

Unguenti petrolati § ij. 

M. 






.._; ' - - r - — . ..— -^ ,'■. ■' ■ - 

Fig. 11.— Epidermis scale in herpes tonsurans, showing more mycelia than conidia (Kaposi). 

The most powerful parasiticides, when well borne, are pyrogal- 
lic acid ten per cent, or chrysarobin ten per cent, or alcoholic subli- 
mate solution 1 : 100. 

Herpes tonsurans (kpnt}?, creeping eruption; tondeo, to shear); 
herpes circinatus ; ringworm. — A disease of both hairy and free 
surfaces, caused by the growth on and in the skin of the trichophyton 
(hair-like) tonsurans — long, narrow threads which divide but little, 
form no masses, but much more readily invade the hair. 

The parasite is common to domestic animals, dogs, cats, cattle, 
between which and man the disease is transferable. It may be cul- 
tivated in beef infusions, on agar, potato, etc. 




ECTOZOA — VEGETABLE. 13 

On the scalp it attacks and bends or breaks off the hairs, to leave 
partly bared, as if badly cut, or later bald, spots, smooth, scaly, or cov- 
ered with pustules or crusts with more or less reddened edge. The 
hairs look dull and dusty, and the skin of the scalp is lightly infil- 
trated with serum and is slightly sensitive to pressure. 

On a free surface the disease 
appears in small vesicles upon a - f h ; \, >: 

reddened base. The vesicles nip- '. r ; ! -L. > '"■-_■' ;■;; :\ 
ture, to leave the red points cov- ' l - :'i 

ered with small scales. In the : 

progress of the disease new ve- ; - , ; V x y. 1 

sides develop in the form of a 
ring about the first set, while 

the original centre fades to leave ■ " "%, 

no trace. The process repeats ? ; " i] 
itself in this way with an ad- ;<|fe 
vancing circular or serpentine -> : 

wall of vesicles, or contiguous '/>"■ / -, 
rings break into each other to ^^ i'i' i 'i i V.i -■ ^ kfi '''''te i- f 
aggravate the inflammation and fig i5.-Hair in herpes tonsurans, 

show pustules, crusts, or more 

extensive eczema. Desquamation finally sheds the parasite, and the 
disease ceases spontaneously in six weeks to six months, 

A good illustration of this process is often seen on delicate surfaces 







;>v'"V 



Fig. 13.— Onychomycosis. 

kept warm and moist by apposition, as where the skin of the scrotum 
rests upon the inner face of the thigh. Maceration with abrasion of 
the epidermis forms here a good nidus for the parasite, which ad- 
vances with an outlying marginal ring of papules to constitute the 
affection known as eczema marginatum. The finer forms of myce- 



14 ECTOZOA — VEGETABLE. 

lia sometimes found in this affection have received the name mi- 
crosporon minutissimum. 

The nails invaded by the parasite (onychomycosis tonsurans) be- 
come opaque, scaly, and brittle. 

More extensive inflammation results at times from invasion of 
the hairs of the beard, with the formation of papules and pustules, 
which may coalesce to form ulcers with wide infiltration of the skin, 
constituting the condition known as the parasitic sycosis menti. 
The disease is contracted in barber shops. The common acne men- 
tagra is also parasitic, but is produced by the Staphylococcus au- 
reus. 

Treatment. — During the stage of vesiculation or abrasion on a 
free surface, no other treatment is necessary than the use of some 
inert powder, as of starch, to prevent contact with air or with op- 
posed surfaces. Later stages call for : 

1 R /?-naphthol ... 3 ss. 

Saponis viridis = 3 ii. 

M. 

2 R Acidi pyrogallici 3 i. 

Unguenti petrolati 3 x. 

M. 

3 R Hydrargyri chloridi corrosivi, Aquae destillatae, 1:1000. 
M. 8.: Wash the surface three times a day. 



On the hairy scalp successful treatment requires, in addition to 
softening of crusts with olive, almond, or cod-liver oil, removal of 
dead or diseased hairs, with subsequent destruction of the fungus by 
one of the parasiticides mentioned. Penn applies sublimate with elec- 
tricity. The sponge of the positive pole is dipped into a three- to five- 

per-cent sublimate solution and 
applied to the affected region 
ten minutes with a current not 
too strong-. 




Pityriasis versicolor is 
that discoloration of the sur- 
face, pretty uniformly yellow 
or brown, not so variegated as 
the name implies, which results 
from the deposit and growth of 
the microsporon furfur, a vege- 
table parasite distinguished only from those hitherto described by 
its smaller size and more superficial growth. It develops by prefe- 
rence upon warm, moist surfaces of the trunk, neck, flexures of the 



Fig 14. —Microsporon furfur: a 
threads; b, conidia; c, epithelium. 



mycelium 



ECTOZOA — VEGETABLE. 15 

joints, etc., and is most commonly seen on the skin over the pit of 
the stomach, especially in the uncleanly or phthisical, patients who 
sweat much. The discolorations vary in size from minute spots to 
tracts which may by spread or coalescence cover large regions of the 
body. 

Treatment. — Friction with carbolic acid, sulphur, or naphthol 
soaps usually suffices to reach this parasite. The following is an eli- 
gible preparation : 

B /S-naphthol gr. x. 

8piritus lavandulse 3 i. 

Saponis viridis 3 i. 

M. 

Other forms of pityriasis — viz., rosacea, maeulata. circinata — and 
various dermatomycoses — erythrasma. etc. — are produced by allied 
hyphomycetes. Carter considers the Madura disease, in which tumors 

Fig. 15.— Pityriasis ; mycelia and conidia. Fig. 16.— Mycoderraa albicans. 

and ulcers form on the hands and feet, the so-called fungus disease 
of India, as a mycetoma. Certain diseases of invertebrate anim Is 
are found to be due to fungi. The silkworm is destroyed by the 
muscardine, Botrytis Bassiana ; the crab by penetration of its flesh 
by the Achyla prolifera; and the common house fly is killed by pene- 
tration of the mycelia of a species of empusa. 

A^transition from the external to the internal parasites is offered 
in thrush and actinomycosis — affections of the mucous membrane 
and deeper structures of the mouth. 

Thbush (thrush ; curd; German, Soor; French, miiguet). — A su 
perflcial disease of the mucous membrane, mostly of the mouth, caused 
by the deposit and development of the thrush fungus (XEyeoderma 
albicans), and characterized by the formation of white spots and sur- 
faces non-adherent or but loosely adherent to the epithelial layer, 
clinically by sore mouth and dysphagia. 

The thrush fungus was formerly regarded as the Oidium albicans, 
but since it has been observed to grow by the budding process it is 




16 



ECTOZOA — VEGETABLE. 



classed among the ferment fungi and called the My coderma albicans. 
It is readily recognized by its mycelia and conidia, and may be cul- 
tivated on various soils. It has a wide distribution in nature, but not 
much affinity for the soils offered in the body of man, as it develops 
on the mucous membranes only of the weak and debilitated or in 
persons of unclean habits. It is found in the mouths of sucklings, 
especially in cases of gastrointestinal catarrh or in cases of use of 

unclean utensils for food, espe- 
cially unclean nursing bottles and 
nipples. It is seen also upon the 
breast nipples of nursing women 
careless as to cleanliness ; and 
these two sources, the natural 
and artificial nipple, introduce 
the disease to the mouth of the 
child. 

Typical cases are also encoun- 
tered in the adult where the body 
has become debilitated by long- 
standing disease, typhoid fever, 
tuberculosis, diabetes, or any ma- 
rasmus. In the last stages of tu- 
berculosis the whole interior of 
the mouth and pharynx, as far 
as may be seen, may be lined with 
thrush. 

The fungus is also found upon 
other mucosae — larynx, oesopha- 
gus, stomach, vagina, glans penis, 
and rectum. It lies at first under 
and in the epidermic layer of the 
mucosa, but is speedily exposed 
by desquamation and is found 
mingled with epidermic scales, 
detritus, and the myriad bacteria 
of the mouth. Occasionally, as 
a great exception, it is carried by metastasis to distant organs. Thus 
Schmorl found it in the kidney, and Zenker (sole observation) in mul- 
tiple abscesses in the brain. Such transfer is exceedingly rare, but 
the possibility of it has been proven in animals by Klemperer, who 
produced a general mycosis by injection of it into the blood of the 
rabbit. Aspirated into the lungs of man, it helps to produce the 
catarrhal (Schluck) pneumonia of paralyzed, reduced, debilitated 
(senile) patients. 




- ; '.^- 






>k 







Fig. 17.— Transverse section of flake of coat 
of tongue after death in typhoid state, covered 
with my coderma (Dickinson). 



ECTOZOA — VEGETABLE. 



17 



Symptoms. — Thrush may be latent. In fact, most cases of light 
deposit hitherto unsuspected are recognized only by inspection — as of 
the process of dentition, for sore throat, etc. The disease shows 
itself at first as small pinhead deposits of white cheesy matter, bor- 
dered with a red ring, upon the surface. The points coalesce to form 
large surfaces, which may coat extensive areas or absolutely line the 
whole cavhy. The deposits may be detached without much break of 
surf ace — i. e. , without haemorrhage — to leave a lightly reddened, hard, 
slightly abraded base, which is tender to the touch. The secretions 
of the mouth are always acid, not, however, in a necessary relation 
to growth of the fungus, as Kehrer showed that it will thrive in solu- 
tions of the lactate of soda and potash. 




Fig. 18.— Thrush fungus : a, mycelia with polar granules; b, conidia; c, epithelium; d, leucocytes. 

When present in any quantity it causes soreness of the mouth, 
with consequent aversion to food and at times even difficulty of deg- 
lutition. 

Diagnosis. — The disease is usually recognized at a glance, even 
though the color may be changed, by admixture with food or foreign 
matter, to a dirty gray or brown. The deposit is confined to the 
surface of the tongue, cheeks, lips, or only later involves the throat, 
and then without the adenopathies which distinguish sore throat 
from other causes. In case of doubt the microscope reveals the true 
character of the deposit. The specimen, best examined in glycerin, 
shows leucocytes, detritus, conidia (spores), and threads with clear 
contents, each section of which contains two polar granules. 

Treatment. — Prophylaxis is a main element. The disease may 
be avoided by care of the mouth and scrupulous attention to utensils, 
nursing bottles, nipples, etc., which should be boiled, steamed, and 
washed in soda. In fact, bottles and nipples should be dispensed 



18 ECTOZOA— VEGETABLE. 

with as soon as possible. All expenditures of patience in feeding 
with the spoon and from a glass (not a cup, even though of silver 
or gold) will be thus amply rewarded. The oral cavity of patients 
with prostrating maladies (the tuberculous, etc.) must be cared for 
every day. The child^s mouth may be best washed out with clean 
linen rags dipped in five- to ten-per-cent solutions of soda or borax. 
Deposits of thrush may be thus mechanically washed away, and the 
parasite itself dislodged and destroyed. The base may be touched 
with nitrate of silver (two-per-cent) or with — 

R Potassii permanganatis gr. v. 

Aquas destillatae § i. 

M. Apply with cameFs-hair brush. 

A very mild, safe, and efficacious remedy is methylene blue, two- 
or three-per-cent solution, applied with a brush. 

Syrups, because they favor the development of fungi, should be 
always avoided in the preparation of any remedy for thrush. 

The general health must be fortified by the tincture of iron,' 
malt, cod-liver oil, fresh food, and open-air exercise. 

The Leptothrix buccalis is the common fungus which abun- 
dantly infests the mouth. It is found on 
the coat of the tongue ; on the teeth, to the 
caries of which it is said to contribute; and 
in the crypts, cheesy contents, of the ton- 
sils, where it produces a form of tonsillitis 
which simulates in its deposits and symp- 
toms a beginning diphtheria. The lepto- 
thrix may be always recognized by its 
fig. 19. -Leptothrix buccalis. mycelia. Under the iodine-potassium-io- 
From tartar of teeth. dide solution it takes on a purple color. 

Actinomycosis {anrk, axTivos, ray, /xvx?/,, fungus) ; big jaw, 
swelled head, bone tumor ; German, Kinnbeule, Holzzunge, Knoch- 
enkrebs. — A peculiar infection of cattle as well as man, caused by the 
ray fungus, actinomyces, characterized by development of the fungus 
in mass, with excessive overgrowth of the soil in which it grows, at- 
tended by metastases to different organs, marked by symptoms of 
pyaemia and marasmus, and distinguished always by the detection of 
particles of the fungus itself in the mass, in its metastases, and in its 
discharges. 

History. — Bollinger (1877) first saw the fungus as the cause of 
the disease known as the big jaw in cattle. Israel, of Berlin, saw the 
parasite in man in the same year of its discovery in cattle, and de- 
scribed it as a new mycosis of man. Ponfick (1879) established the 
identity of the disease it caused in man with the actinomycosis of 
cattle. Belfield, of Chicago, first recognized the parasite in cattle in 




ACTINOMYCOSIS. 19 

our own country as the cause of the disease known as swelled head, 
-technically as a jaw sarcoma. 

Pathology.— Actinomyces constitutes a mass so large as to be 
visible to the naked eye. It consists of a conglomeration of innu- 
merable threads of mycelia about a central mass of the same struc- 
ture, from which the threads radiate in every direction to construct 
the ray shape. The mycelia can be always recognized by their 
clubbed extremities, and the mass, on an average about one-fortieth 
of an inch, is as large at times as one-tenth of an inch in diameter. 
Agglomerated masses may be as big as a fist. Fragments detached 
and discharged have a tallowy consistence and a distinctly greasy 
feel. Peripheral protrusions divide dichotomously, and show, as 
stated, distinctly clubbed- or pear-shaped extremities, to resemble in 
certain fragments the appearance of a hand or glove with out- 
stretched fingers. The peripheral radiation from a central mass 
gives, under the microscope, something of the appearance of an aster 




Fig. 20. 




Fig. 20.— Actinomyces. 

Fig. 21.— Actinomycosis of the tongue: a, actiDomyces mass; b, cell masses; c, pus corpuscles: 
<L muscle tissue, cross-section; e, ditto, longitudinal section; /, blood vessel (Ziegler). 

or sunflower. Many deviations, however, may occur from this clas- 
sical type. The size of the individual mass may vary from barely 
visible granules up to masses of measurable diameter. 

Besides the typical yellow color, particles may be seen colorless, 
transparent, greenish, or brown. The young granules are whitish- 
gray, the very youngest gelatinous, almost diffluent ; the other colo- 
nies are opaque, and the oldest yellowish-brown and yellowish-green. 
The surface may be granulated, mulberry form. Harz and Johne 
tried in vain to cultivate it. Israel finally succeeded with coagulated 
blood serum, but with such different appearance from the normal 
structure as to make it impossible to decide upon the exact botanic 
relations of the microphyte. Bostrom succeeded best with granules 
floating free in pus or lying loose in granulation tissue. Wolff 
finally inoculated the disease with pure cultures of actinomyces. 
The mass is colored with difficulty, though the mycelia at the peri- 
phery absorb the aniline dyes, especially gentian violet, and retain 



20 ACTINOMYCOSIS, 

them. Fine pictures are made with double colorations, as by the 
method of Gram, and subsequent stain with eosine. 

The pathology of the affection differs in man from that of the 
lower animals, in that the process in the animal is a local swelling, a 
so-called granulation tumor, while in man the tendency is toward 
a suppurative process with metastatic dissemination. So that the 
disease in man runs its course with the formation of multiple ab- 
scesses, under the picture of a chronic pyaemia. The difference is 
explained by the belief that the process is not pure in man, but is 
attended with mixed infections, especially with the penetration of 
the pyogenic micro-organisms. Of the nine cases reported by Baracz, 
in only one was there a pure actinomycosis; in all the others there 
was subsequent infection with the micro-organisms of pus. The 
suppurative process in man is attended also with a distinct tendency 
to extensive fatty degeneration. Preparations of the granulation tis- 
sue show great accumulations of fatty degenerated cells. 

Etiology. — The most frequent avenue of entrance in man is, as 
stated, the cavity of the mouth, and especially the teeth whose sur- 
face is broken with caries ; next the bones of the jaw ; less frequently 
solutions of continuity in the pharynx and tonsils. More than half 
of all the cases hitherto observed in man have arisen in this way. 
The origin of the disease is ascribed to the ingestion of vegetable food, 
especially certain cereals (barley). The avenue of entrance in man 
bespeaks the same origin, that is, some vegetable source. 

Symptoms. — The disease demonstrates itself as a torpid and but 
slightly painful growth, which finally perforates the skin with sin- 
uous tracts and various fistulous orifices. Some, if not most, of 
the great tumors or masses in the region of the lower jaw, formerly 
diagnosticated as cases of angina Ludovici, which constituted .in an- 
cient times a much-dreaded malady, were certainly cases of actino- 
mycosis of the lower jaw. Besides the penetration of the teeth, the 
parasite finds entrance into the body of man by way of the bronchi 
and also by way of the intestinal canal. Thus there is an actinomy- 
cosis of the jaw, of the lungs, and of the intestine. The disease dis- 
tinguishes itself by its gradual encroachment upon tissues, hard and 
soft, in its vicinity. It expands bone, enlarges the natural outlines of 
the neck, converting the skin into a mass of cicatricial tissue, finds 
its way at times into the anterior mediastinum, and finally, after a 
lapse of months or years, causes the death of the individual by a slow 
process of suppuration or by a quicker suffocation or occlusion of 
larger vessels. 

It may be distinguished upon the surface by the mass of cicatri- 
cial tissue, by the formation of abscesses with subsequent discharge 
without offensive odor, often through fistulse of sinuous tracts, and 



ACTINOMYCOSIS. 21 

absolutely by its yellowish granules, of the size of grains of sand, 
visible to the naked eye, greasy to the feel, which, when placed under 
the microscope, reveal the distinctive characteristics of the growth. 

Entering the bronchial tubes, it produces a peculiar form of 
bronchitis, most closely allied to putrid bronchitis, save that the of- 
fensive discharge which is expectorated separates into two instead of 
three layers — an upper supernatant, and a lower, turbid fluid con- 
taining the actinomyces. In the lungs proper the disease gives rise 
to the symptoms of tuberculosis, and has been not infrequently mis- 
taken for this disease. The gradual decline of health and strength, 
the progressive emaciation, cough, suppuration, night sweats, 
make it closely resemble tuberculosis. In cases of more rapid prog- 
ress the disease may simulate pneumonia with its glutinous, mu- 
co-purulent, or rusty sputa, dulness to percussion, and bronchial 
respiration. Metastatic processes from these centres disseminate 
the parasite to distant organs, most frequently to the subcutaneous 
and intermuscular connective tissue, and also to the various viscera 
— liver, kidneys, intestine, heart, and brain. The eruption into the 
various serous cavities — pleura, pericardium, peritoneum, meninges — 
quickly causes fatal inflammations. Cases which escape these calam- 
ities survive to succumb to amyloid degeneration with anasarca, 
and more protracted marasmus, whereby the disease may last two or 
three years. 

In the intestine the mucous membrane shows whitish patches 
covered with yellowish granules, firmly adherent to the membrane 
upon which they rest. Various swellings appear, therefore, in its 
course, some of which suppurate and discharge their contents at 
times into the peritoneal sac, or by successive agglutination to the 
surface of the abdomen with subsequent free discharge. Metastases, 
which are rare on account of the size of the growth, carry fragments 
to the liver, where they may attain.considerable magnitude. So me- 
tastases through the jugulars have developed into masses in the lung 
and heart. 

Diagnosis. — The disease may be distinguished from ordinary af- 
fections of the jaw by its long duration, its tedious suppuration, its 
recurrence after incomplete exsection. its periods of quiescence, and 
defiance of all ordinary treatment. In the lungs it affects the pos- 
terior and lateral portions, rarely the apices, and in the intestine it 
reveals nodular masses which may at times be felt beneath the sur- 
face. But neither the enlargement, suppuration, nor general symp- 
toms absolutely declare the disease, whose nature is only definitely 
established by the recognition of fragments of the parasite with 
the eye and its characteristic elements under the microscope. Cer- 
tain apparently inscrutable cases of crypt ogenetic infection have 



22 ACTINOMYCOSIS. 

been unveiled as actinomycoses. One of the most remarkable of these 
cases was that mentioned by Bollinger of an apparently primary ac- 
tinomycosis of the brain. Fischer remarks that the presence of vege- 
table fibres in the purulent discharges should excite suspicion of 
the etiology of the disease. 

Prophylaxis includes the supervision of the food of animals ; the 
avoidance of thorny and prickly twigs and plants, as well as of moist 
or wet food ; the absolute destruction, as by fire, of all actino- 
myces in diseased organs of slaughtered animals; and enjoins, above 
all things, the most scrupulous care of the teeth and mouth. 

Treatment. — The treatment is almost entirely surgical. It con- 
sists in the complete exsection and enucleation of the entire mass 
with the knife, or its thorough eradication and destruction with 
caustic. The parasite seems to be singularly susceptible to the ni- 
trate of silver. Kottnitz cured four cases with the solid stick, ap- 
plied and inserted freely in every direction. Favorable results — i. e. , 
destruction of the growth and rescue of the patient — have been 
secured in individual cases by injection of the ferric sulphate, tinc- 
ture of iodine, carbolic acid, or sublimate, as also by cauterization 
with the zinc chloride and the internal use of potassium iodide. 
Gautier reports the cure of a case by the electro-chemical treatment 
— i.e., by the hypodermatic injection of a ten-per-cent solution of 
potassium iodide into the dead tissue, followed by the insertion of 
needle electrodes through which was passed a current of fifty milam- 
peres for twenty minutes. Billroth cured a refractory case with 
fifteen injections of tuberculin. 



CHAPTEE II. 

EXTOZOA. 

Of the whole number of the grosser parasites of man, now in the 
neighborhood of sixty, twenty-one occupy the interior of the body as 
the so-called entozoa. ATost of these forms are so rarely found as to 
constitute clinical curiosities, and many of them have never been 
observed in our country. In fact, but four varieties — the tapeworm, 
the round worm, the threadworm, and the trichina — are so commonly 
encountered as to demand especial study by the practitioner of medi- 
cine. 

Tapeworms (Latin, taenia ; Greek, ralvia, a band; cestodes, 
h8(dt6z, belt, sidoz, like). — Of the three hundred species of taeniae in 
the whole animal kingdom, but four are found in the body of man, 
viz., in the order of frequency in our country, the Taenia saginata, 
armata, echinococcus, and lata, or Bothriocephalus latus, derived 
respectively from the ox, pig, dog, and fish. 

History. — The first recognition of a difference in the varieties of 
tapeworm was made by Felix Plater (1602) with the discovery of the 
Bothriocephalus (fioOpoz, a pit) latus, thus named by Rudolphi (1S10). 
The Taenia mediocanellata or saginata was separated from the armata 
by Kiichenmeister (1852). The Taenia echinococcus (sx ivo ^, hedge- 
hog) was first distinguished as a living thing by Pallas (1760), and its 
scolices {axoXw?, crooked) recognized as tapeworm heads by Pastor 
Goze (1782). Except in the case of the bothriocephalus, the larva of 
which has recently been discovered by Braun, of Dorpat, the devel- 
opment of the larval into the mature form, in all the varieties of 
taenia in man, was demonstrated by the feeding experiments of Ben- 
eden, Siebold, Leuckart, and more especially Kiichenmeister, who 
verified his observations on animals in the bodies of criminals which 
he was permitted to use. 

Anatomy, etc. — The whole animal in its maturity consists of a 
head (scolex), a slender neck which at some distance from the head 
shows transverse folds or wrinkles, deepening later or lower down 
into furrows, which indicate the separate segments (proglottides) of 
the body. The head of the tapeworm is oval, about the size of a 



24 



ENTOZOA. 



pin's head, and is provided with from two to four equidistant suckers 
about its upper surface. The segments, from four to twelve hundred 
in number, are at first longer than broad, then in some cases quadrate, 
and finally broader than long or extremely oblong. Upper are let 
into lower segments, and the union, firm at first, becomes more lax 

toward the end of the worm, where de- 
tachment readily occurs. New segments 
are always produced from the neck, so 
that the last segment is always the last 
so long as it remains united to the rest. 
Hence the necessity of securing the ex- 
trusion of the head in the total extirpa- 
tion of the worm. Each segment con- 
tains or is filled with the generative appa- 
ratus of both sexes; hence the animal is 
hermaphrodite. It is also self-impreg- 
nating. The bulk of the segment is taken 
/ Mimm fill U P ky the uterus, which forms an elon- 
gated central cavity with radiating 
branches stuffed with eggs. The male 
element is comprised in a bunch of semi- 
nal vesicles which empty into a seminal 
duct terminating at a pore in the lateral 
margin of the segment, common to the 
uterine opening or vagina. These genital 
pores are disposed alternately, or on op- 
posite sides of the different segments. 

The tapeworm fastens itself by its 
suckers to the mucous membrane of the 
small intestine, the body floating free in 
loose folds or elongated along the course 
of the canal, from the contents of which 
it imbibes nutrition by osmosis. The 
contents of the large intestine will not 
support it. Robin found one extending 
into the large intestine, the head fastened 
at the pylorus, the anterior end being 
rolled up into a coil as large as an apple. 
Portions found in the large intestine are in process of expulsion. It 
is feebly endowed with motion, so that detached segments voided 
with faeces may migrate by slow vermicular action a few feet from 
the seat of deposit. More extensive change of place is effected by 




Taenia saginata ; seg- 



ments natural size. 



outside agencies- 
ing animals, etc. 



-running water, processes of manuring, wander- 
Each segment may contain as many as 53,000 



EXTOZOA. 



25 



eggs, so that a tapeworm producing 800 ripe segments a year may 
furnish an annual contribution of -42,000,000 eggs. Fortunately, in 
the struggle for existence myriads fail to find the necessary condi- 
tions for development ; thus Leuckart calculates the chances of de- 
velopment of an egg to a cysticercus as 1 to 1,340, and to a mature 
worm as 1 to 85,000,000. The tapeworm may live in an intestinal 
canal from ten to fifteen years. Segments may retain vitality out 
of the bodv for ten years. 





Fig. 23.— Segments in motion. 



Fig. 24.— Ova containing embryos 
of Taenia saginata. X 350. 



The egg of a tapeworm is a rounded or ovoid body provided with 
a thick envelope containing an embryo endowed with hooklets. Re- 
ceived into the body of an appropriate host, it is freed of its envelope 
by the action of the gastric juice, protrudes its head, and appears in 
the form of a larva. The larva is, of course, an undeveloped tape- 
worm. It has the same head and neck, much reduced in size, but 





Fig. 25. Fig. 26. 

Fig. 25.— Calt* s heart with measles of Taenia saginata - 
Fig. 26.— Cysticerei: a andb, of pig ; c, of ox. 

'the body remains a vesicle. It is always provided with hooklets, by 
means of which it bores its way through the walls of the stomach or 
intestine, to be lodged in adjacent structures, or to be carried off by 
the lymph or blood current to distant organs, where it may excite 
a destructive inflammation, or, encysted, remain innocuous. The 
muscular structure of the body is the soil of predilection, and muscle 
thus affected is said to be " measly, " from measle, a spot. In the 
^course of three or four months the vesicle attains its full develop- 



26 ENTOZOA. 

ment to the size of a large pea ; the larva becomes a cysticercus 
(kvStiS, bladder, uepHoS, tail). 

Cysticercus cellulosa. — The pork tapeworm infests the body of 
man both in its mature form as the developed tapeworm, and the 
immature form as the cysticercus ; but, as the liberation and de- 
velopment of the eggs of the segments may occur only accidentally 
in man, the presence of cysticerci is a rarity. Thus Karenski found 
them but nine times in eight thousand five hundred autopsies. Pigs 
which have access to the faeces of man are the natural hosts of cysti- 
cerci, and pigs thus infested show signs of disease, according to the 
location of the cysticerci. When present in great numbers (one 
pound of meat has been known to contain five hundred and forty 
cysticerci) the animal shows signs of general distress in progressive 
emaciation, oedema, falling of the bristles, etc. ; stupor and convul- 
sive attacks indicate infection of the brain ; alterations in the sounds 
emitted, infection of the larynx ; paresis and paralysis, invasion of 
the muscles of locomotion ; dyspnoea, invasion of the diaphragm, 
etc. Cysticerci select by preference the psoas and iliacus muscles, 
the diaphragm, and the tongue — parts of the animal most prized as 
food. They may be seen on drawing out the tongue, studding its 
under surface like tubercles, which they were formerly considered to 
be. They show also in man the same predilection for muscular 
tissue, being found most frequently in the diaphragm, costal and 
cervical muscles, lying embedded in the intermuscular connective 
tissue, or floating in the pus of abscesses which they cause. Yet 
they are occasionally caught in the lymph and blood currents and 
carried to viscera, as to the brain (seventy-two times in five thou- 
sand three hundred examinations), eye, lungs, liver, kidneys, etc. 
They usually give rise to but little distress, being, as a rule, solitary, 
and, becoming soon encysted or calcified, they remain as foreign 
bodies during the life of their host. They have been seen in the eye 
with the ophthalmoscope, in the vitreous humor and under the con- 
junctiva or retina, which they detach and perforate. The pain and 
inflammation which they cause in this organ necessitate their ex- 
tirpation, or, after failure of this operation, enucleation of the globe. 

The cysticercus lives, as a rule, from three to six years, when it 
perishes and undergoes calcareous degeneration ; but, ingested dur- 
ing its life into the stomach of man, it attaches itself to the small 
intestine, and reproduces segments which become sexually mature 
in the course of three or four months. Periods of quiescence may 
occur. Bettelheim records a case in which no segments were given 
off in the space of three years. Ordinarily but one tapeworm is 
found in the body of man, yet there are abundant instances of the- 
presence of two or more of the same or different varieties at the- 



EXTOZOA. 27 

same time, or of their coincidence with other forms of intestinal 
worms. Of three hundred cases examined by Krabbe, Taenia sa- 
ginata occurred one hundred and ninety times, always solitary ; 
Taenia solium seventy-seven times, multiple in thirteen cases up to 
ten worms. Beranger-Feraud once found twelve in the body of one 
individual, and Kleefer, of Gorlitz, records a case in which forty-one 
taeniae were discharged with heads. Roux saw ninety Bothrioce- 
phali lati, half filling a vessel, voided at once from a healthy child ; 
and Lister and Botticher each report cases where one hundred were 
discharged, all, of course, small and young. 

The different varieties of tapeworm may be readily distinguished. 
I. The Tcenia armata (armed), or pork tapeworm ; Tcenia solium. 
from Syriac schuschl-e (chain), Arabic corruption susl or sosl (not 
from solus, alone, because less frequently found alone than any 
other form), is known by its coronet of from twenty-two to thirty- 
two hooklets — whence the name armata — on the circular rostel- 





Fig. 27.— Measles in pork. Fig. 28.— Pork tapeworm. Head with hooklets. 

lum of its head, which is likewise provided with four small circular 
suckers. Its segments number from seven hundred and fifty to 
eight hundred and twenty-five, and become sexually mature at the 
four hundred and fiftieth member, as recognized by the presence of 
the genital pore, so that the worm may reach a length of from seven 
to ten feet. They are at first longer than broad, then quadrate, and 
finally extremely oblong, whence the synonym cucurbitina. They 
are rarely discharged except at stool. The uterus consists of a 
median cavity, never quite reaching the upper or lower margins, 
with from seven to twelve lateral branches, radiating irregularly 
like the branches of a tree— hence dentritic. Its larva, the Cysti- 
cercus cellulosa, provided with four suckers and six hooks, is found 
in the tissues of the pig, dog, deer, rat, sheep, ape, and bear, as well 
as in man in the liver, subcutaneous connective tissue, muscle, eye, 
and brain. Its circular ova contain also six hooklets. The Taenia 
armata is found wherever raw or half -cooked pork is used as food. 

II. The Tcenia sacjinata (fat), or beef tapeworm— erroneously 
called mediocanellata by its discoverer, the narrow, cylindrical ute- 



28 ENTOZOA. 

rus having been mistaken for a median canal; sometimes still called 
lata because of its breadth — is known by its greater thickness 
and breadth, whence its name. Its head is larger and more square, 
and, being devoid of a rostellum and hooklets, more flat on the top. 
It has likewise four suckers (though there is of this species, as well 
as of the armata, a variety which has six). The whole worm, espe- 
cially the head, is darker, from the presence of more pigment matter 
than the Taenia armata; the neck is shorter and broader. It is larger 
than the Taenia armata, its twelve hundred and more segments mea- 
suring from ten to fourteen feet. Each segment is broad and long, 
often one-half by one inch. The body of the uterus quite reaches the 
upper and lower margins of the segments; but it is more narrow than 
in the armata, and all its branches are finer. These lateral branches, 
more numerous than in the Taenia armata, fifteen to twenty-seven on 
the side of the genital pore, thirty-one on the opposite side, are always 
given off dichotomously. The segments are voided not only at stool, 





Fig. 29. Fig. 30. 

Fig. 29.— Head and neck of Taenia saginata. 
Fig. 30.— Head of Taenia solium within that of Taenia saginata, to show differences (Heller). 

but often also spontaneously. Acetic acid renders the segments trans- 
lucent, and displays the uterus with many branches in the Taenia 
saginata, few in the Taenia armata. Patients who are continually or 
occasionally discovering detached fragments in their clothes are nearly 
always hosts of the Taenia saginata. Its larva is found in cattle and 
various other ruminants, but not in man. Its eggs, of which each 
segment may contain thirty-five thousand, are oval, larger than those 
of the Taenia armata, and devoid of hooklets. The Taenia saginata is 
found wherever rare or raw beef is used for food; consequently much 
more frequently in our country than the Taenia armata. The Taenia 
saginata is now the common tapeworm. Leidy states that the tape- 
worms from Philadelphia and its vicinity, which he had occasion to 
examine in the last twenty years, " perhaps in all about fifty," were 
specimens of the Taenia saginata. The condition assumes epidemic 
proportions in Abyssinia, where the flesh of cattle is eaten while still 



ENTOZOA. 29 

quivering with life. Knox reports the existence of the condition in 
epidemic proportions in the English army during the Kaffir war. A 
mature worm was raised from a beef " measle," purposely swallowed 
by a student, in fifty-four days. 

III. The Taenia lata, or Bothriocephalus latus, differs in marked 
degree from the preceding varieties. It is the largest of all the tape- 
worms, its four thousand segments attaining a length at times of 
twenty-five feet. The head is long and narrow, and is slit at the 
sides to form the bilateral elliptical suckers which give the worm its 
name. The segments, not sharply separated, are from two to four 
times as broad as they are long. The central uterus has the appear- 
ance of coils of intestine. The genital pore is situated on the ventral 
surface. The cysticercus is provided with spicuke and a ciliated 
envelope, by means of which it swims in water. The eggs are oval, 
and are furnished with a lid (operculum) at one end to afford escape 
for the embryo. This species of tapeworm is found wherever raw or 
partially cooked fish is used as food; consequently in Russia and 
Sweden, East Prussia, Poland, and parts of Switzerland — not in our 





W 

Fig. 31.— Head and neck of Taenia lata. Fig. 32.— Ova of fish tapeworm. 

country. The sole specimen thus far reported in our country was 
found by Leidy in the body of a recently immigrated Swede. The 
mature Tasnia lata is found in the intestine of the dog as well as in 
man. 

Symptoms. — Mature tapeworms are seldom dangerous to man. 
In many cases they produce no symptoms of any kind, and their 
presence is recognized for the first time upon the post-mortem table, 
or in the discharge of segments with the stools ; the appearance of 
them in clothes at other times is the first indication of their presence. 
Individuals who use water closets may thus entertain these guests 
unawares, until on some occasion the faeces are voided visibly, as 
upon the ground in the open air, or in a night vessel. As no mature 
worm penetrates the intestinal canal or evolves noxious products, 
what symptoms do occur are due to mechanical irritation of the in- 
testinal walls or are reflex manifestations. Thus, anorexia, nausea, 
vomiting, colic, diarrhoea, alternating perhaps with constipation, 
heartburn, pyrosis, flatulence, the group of symptoms characteristic 
of gastric catarrh, summed up under the vague term dyspepsia, and, 
as effects, lassitude with malaise and depression of spirits, are not 
infrequently present. A ravenous or insatiable appetite is excep- 



30 ENTOZOA. 

tional, and when present is due. not to the consumption by the para- 
site of nourishment, which is insignificant in amount, but to reflex 
irritation or defective assimilation, the result of irritation. More 
importance may be attached to morning vomiting, which, in the 
absence of more common causes — pregnancy, gastric catarrh, cirrho- 
sis, tuberculosis, B right's disease, etc. — may be an index to the con- 
dition. Young children or highly sensitive adults may exhibit more 
pronounced disturbances of the nervous system. Thus dilatation 
of the pupils, itching of the nose and anus, palpitation of the heart, 
choreic manifestations, even veritable convulsions and epilepsy, have 
been observed in these cases. But the symptoms caused by intestinal 
parasites are exaggerated as a rule. All the symptoms mentioned 
may be produced by any cause that will excite the same irritation, 
and grave accidents are to be attributed to tapeworms only in cases 
where symptoms subside with the expulsion of the worms. Rare 
instances of this kind are recorded. Thus Williams describes the 
case of a young girl who was cured of a periodically recurring blind- 
ness and deafness of several hours' duration by the extirpation of a 
tapeworm ; and Homolle reports a case of epilepsy relieved in the 
same way. Commini cured a case of epilepsy by causing the dis- 
charge of a tapeworm, which had been voiding segments spontane- 
ously. The disease returned with the reappearance of eggs in the 
stools. 

In a few cases grave symptoms admit of a different explanation ; 
for especial danger attaches to the pork tapeworm, in that the deglu- 
tition of its eggs or their premature discharge into the intestinal 
canal may lead to the development of cysticerci in the same host. 
This accident may take place in sleep, when the hand is used to 
relieve itching or irritation at the anus, or the moist segments escap- 
ing at the anus and crawling about on the skin are grasped in order 
to relieve the unpleasant sensations. Kuchenmeister often found 
fingers contaminated in this way. Cases of self-infection have also 
happened from careless handling of worms after their expulsion. 
Moreover, the act of vomiting may introduce segments into the 
stomach, where eggs may be liberated to develop into cysticerci. 
Seeger mentions six cases of ejection of tapeworms by the act of 
vomiting, and Rebsamen reported the case of a woman who with- 
drew a Taenia lata from her mouth with her fingers. Frankenhausen 
related a case of cysticercus in a patient who had previously vomited 
a tapeworm, and Lewis collected a number of such cases. In two of 
Graefe's cases of cysticercus of the eye, the patients, while hosts of 
the worms, had suffered from the vomiting of pregnancy ; and in the 
case of cysticercus of the brain reported by Moller the patient had 
Iiad a tapeworm expelled twenty years before death. Thus the 



ENTOZOA. 



31 



existence of severe nervous symptoms might awaken the suspicion 
of the presence of cysticerci. But examples of this kind are very 
rare. In the vast majority of cases grave nervous symptoms, which 
are not pure psychoses, are due to other and more obvious causes. 
As curiosities may be mentioned the escape of tapeworms through 
previous openings at the umbilicus, into the bladder, etc. 

The diagnosis of tapeworm is sometimes quite obscure. The 
only positive proof of the existence of tapeworm in the body is the 
presence of segments in the stools or clothes. As in most cases 
eggs are not discharged in the intestines, it is very rare to find them 
in the stools. Where reason- . 



able doubt exists, the adminis- 
tration of a cathartic, or of an 
anthelmintic to be followed by 
a cathartic, may secure .the 
proofs. Foreign bodies, shreds 
of inspissated mucus, most fre- 
quently shown, are generally 
recognized by naked-ej'e in- 
spection. Differentiation of the 
form of tapeworm is easily 
made. The segments are flat- 
tened by pressure upon the 
object glass and examined with 




Taenia saginata. Taenia armata. 
Fig. 33.— Segments. 



Taenia lata. 



a power of five hundred diameters, when the characteristic features 
of each form become apparent at a glance. Dried specimens should 
be first softened in water. Acetic acid, as stated, clears up an 
opaque field to make the uterus visible. The occasional evacuation 
of segments independently of stools, or the discovery of them in the 
clothes, speaks in favor of the Taenia saginata. 

Prophylaxis. — The subjection of. meat to a boiling temperature 
throughout its bulk effectually destroys all cysticerci, and thus posi- 
tively prevents the development of tapeworm. The recognition of 
this fact with regard to the Trichina spiralis has already dimin- 
ished the number of cases of pork tapeworm. Cleanliness is the 
factor of next importance. The Oriental custom of ablutions before 
each meal may be commended in this regard. Individuals affected 
with the disease should be enlightened as to the fact that they are 
possible sources of infection of others. Bettelheim speaks of having 
seen in a house of poverty and squalor segments of tapeworm 
deposited upon and crawling about the floor, furniture, and beds. 
Butchers, cooks, all persons employed in the preparation and distri- 
bution of meats, should be cautioned as to the necessity of cleanli- 
ness of hands, instruments, vessels, and clothing. To prevent infec- 



62 ENTOZOA. 

tion of animals with eggs, habits of decency in regard to the deposit 
of faeces should be enforced, and check should be put upon the bar- 
barous custom of promiscuous defecation. A Texas physician in- 
formed Leidy, of Philadelphia, to whom he had sent a piece of measly 
pork for examination, that all the pigs in the place were thus 
affected, and that there was not a privy in the whole village. In 
the administration of anthelmintics to the subjects of tapeworm 
selection should be made of such remedies as will not cause vomit- 
ing. Especial attention is to be paid in this regard to the relief of 
the vomiting of pregnancy. Physicians as well as patients need 
repeated injunction against the careless handling of tapeworms in 
their examinations. Specialists who have devoted a large part of 
their lives to the study of intestinal parasites become exceedingly 
careful in their manipulations. Kuchenmeister states that he al- 
ways handles tapeworms with two pairs of long forceps, seizing 
them as near the points as will secure firm purchase ; and Cobbold 
warns against the danger of leaving specimens about, or carelessly 
throwing them away, with the emphatic injunction to destroy them 
by fire. 

Treatment. — The Greek and Roman physicians possessed sixty 
remedies for the cure of tapeworm, and the number has been greatly 
increased in our day. But few of these agents, however, have stood 
the test of time. Such uncertainty has attended the use of most of 
them as to have left the treatment of the condition a fertile field for 
quacks. This uncertainty depends, however, upon the failure to 
observe a few precautions, the chief of which is the use only of 
fresh, and the avoidance of old or stale, drugs. A second precau- 
tion demands the evacuation of other contents of the bowels as 
effectually as may be, that the remedy used may come in direct con- 
tact with the worm. Elaborate preparatory or supplementary treat- 
ment is now, in the main, superfluous, but a light diet during the 
day, or, better, a fast, broken only by a cup of coffee or a glass 
of milk, should precede the administration of the remedy selected. 
These remedies may be ranked in efficacy as follows : 

1. The bark of the pomegranate root, of which three ounces should 
be macerated in twelve ounces of water for from twelve to 
twenty- four hours, to be then reduced one-half under gentle heat. 
The whole quantity is to be taken in divided doses in the course 
of an hour. Pomegranate root, when fresh, remains the most effec- 
tive of all anthelmintics, and would long since have excluded all 
others, did it not at times produce nausea, vomiting, and colicky 
pains. To avoid the first of these evils Bettelheim suggests the 
introduction of the infusion into the stomach by means of the 
stomach pump ; and to obviate all of them Feraud recommends 



ENTOZOA. 33 

pelletierine. an active alkaloid of the root, named in honor of the 
discoverer of quinine. One to two drachms of the infusion of senna 
are to be taken on the morning following a day of fasting, and in 
the course of an hour fully as much as five grains of the tannate 
of pelletierine suspended in water. The tannate is preferred because 
of its slow absorption. Half an hour later the dose is repeated,, 
to be followed in another half -hour with a tablespoonful of castor oil,. 
the patient remaining meanwhile quiet in bed to avoid disturbance 
of the stomach. In one instance twelve tapeworms were expelled 
at once in this way. 

2. Turpentine is a powerful tseniacide, but the use of it is liable 
to cause headache, pain in the stomach, fever, and strangury. 
These effects are, however, much less frequent after large than after 
small doses. Hence the dose for an adult should be never less than 
one or two ounces, for a child from one drachm to one ounce, accord- 
ing to age. It may be administered in emulsion with white of egg, 
or be briskly stirred in half a glass of milk and swallowed rapidly ; 
should it fail to act as a cathartic, it should be followed with a dose 
of castor oil. 

3. Male fern, the ethereal extract, two drachms in four or five 
gelatin capsules, of which one may be swallowed every five minutes 
with the aid of a cup of coffee. A dose of calomel with brandy 
should follow the capsules in the course of half an hour. Since the 
poisonous principle of male fern is soluble in oils and is thus rendered 
absorbable, calomel and not castor oil should be given as a purgative 
to secure the extrusion of the parasite. 

4. Thymol (which is both a ta3niacide and a tseniafuge), two 
drachms in twelve doses, one every quarter of an hour, preceded the 
evening before, and followed one half-hour after the last dose, by 
half an ounce of castor oil. Alcohol in some form should be given 
with it or after it to counteract its depressant effects. 

5. Kousso, koussin, pumpkin seeds, santonin, kamala, carbolic 
acid, and zinc are other parasiticides of less value. 

The discharges should be passed for several daj r s in a vessel 
of warm water, and all fragments be brought to the physician, that 
he may positively recognize the head of the worm. In no case 
should traction be made during the passage of the worm. Full dis- 
charge can be readily effected during the evacuation by the injection 
of warm water. 

Every attempt at treatment being a forcible intervention, only 
such individuals should be subjected to it as are known to be affect- 
ed. The mere statement of a patient is not sufficient proof, and 
cases of tseniaphobia do not justify it, on so-called psychological 
grounds, because failures only aggravate the condition as a rule. 
3 



34 ENTOZOA. 

Pregnancy, advanced age, debility from any cause, are contra- 
indications to all treatment. 

Finally, the physician must be awake to cases of deception. 
Everything found in a vessel does not necessarily escape from the 
bowels, and the same vessel is sometimes used by others. Bremsen 
says he once found in a vessel a pair of snuffers. Heller reports the 
case of a child finally debilitated by repeated treatment because 
of the continued exhibition of real segments of tapeworm, when upon 
closer examination it turned out that the fragments did not come 
from the child at all, but from a lazy nurse who made a convenience 
of the child's stool-chair. 

IV. The Taenia echinococcus, dog tapeworm — hydatid tape- 
worm, bladder worm — is the smallest of all the tapeworms, measur- 
ing but one-fourth of an inch in length. It lives in the mature state 
in the dog, wolf, and jackal, but not in man. The head resembles 
that of a diminutive Taenia armata, in that it is furnished with four 
suckers, a rostellum, and a double row of hooklets. The segments, 
in number but four, progressively increase in size to the last, which 
is as large as all the rest, and which is alone mature. This taenia 
exists at times in such numbers in the intestine of the dog as to have 
been mistaken for intestinal villi. 

The larva (echinococcus) of this taenia, which infests man and 
many of the herbivora, horse, ox, sheep, etc., differs from that of 
all other tapeworms in that it is endowed with the property of self- 
multiplication to a degree limited only by the restraint of outside 
pressure. The eggs, issuing from the anus of the dog and brought 
often in contact with the nose and mouth of this animal, may be 
thence received into the mouth and stomach of man, where the six- 
hooked embryo is liberated to penetrate the walls of the intestine 
and emigrate to various parts of the body. Infection of man usually 
occurs from . drinking water, raw vegetables, etc. , contaminated 
with dogs' faeces, or from the hair licked by the animal and stroked 
by man. From the fact that the liver is found infested more 
frequently than all the other organs together, sixty-nine per cent 
of cases, the inference is natural that the embryo is carried thither 
by the portal vein. Measly liver fed to dogs reproduces the Taenia 
echinococcus in the intestine of the dog. Having reached its destina- 
tion, in whatever organ, including the bones, preferably viscera, the 
echinococcus develops the hydatid tumor, which may consist of a 
single cyst or, by proliferation from its inner wall, of multiple 
daughter cysts, or from them, in turn, of granddaughter cysts to 
the number of many hundreds. 

The fluid of hydatid cysts is naturally clear and limpid, though 
it may be rendered turbid, opaque, or sanguineous by accidental 






ENTOZOA. 



35 



.admixture of pus and blood. It is distinguished, when clear, by the 
presence of common salt and the absence of albumin. The echinococ- 
cus is rare in our country. But it is safe to say that the majority 
of cases in our country do not find their way into print. For in- 

-* 3 





Fig. 35. 




Fig. 34. Fig. 36. 

Fig. 34.— Taenia echinococcus : '1, natural size ; 2, head ; 3, neck ; 4, 5, immature segments ; 6, 
mature segments; 7, genital pore; 8, ova, 9, containing larva?. 
Fig. 35. —Extended echinococcus with hooklets. 
Fig. 36.— Echinococcus sacs in the liver of man. 

stance, a pathologist at the Cincinnati Hospital, a thoroughly com- 
petent observer, informed the writer, on the occasion of reporting 
"the only case which had occurred in his practice of twenty-six years, 
that he had himself seen three cases since the beginning of his ser- 
vice, less than two years, none of which had been reported. It is 
common in countries where the dog is a most intimate companion of 
man. In Iceland, where the dog shares 
with man both bed and board, the disease 
is epidemic, one-fifth of all sheep and one- 
seventh of mankind being thus affected, 
females, from their indoor life, oftener 
than males. Victoria, Australia, vies 
with Iceland in the f requency of the dis- 
ease. Krabbe, of Copenhagen, found 
twenty-eight per cent of five hundred 
dogs affected with Taenia echinococcus. 

The echinococcus is enveloped in a dense, impermeable, elastic 
capsule, which, upon section, rolls up at its edges to furnish a diag- 
nostic point of great value. From the inner surface of this capsule 
new echinococci develop with characteristic scolices and hooklets. 




Fig. 37.— Echinococcus membrane 
with hooks. 



36 ENTOZOA. 

Diagnosis. — The microscope reveals these structures, shreds of 
membrane, scolices, or hooklets, in the fluid of about half the cases. 
The recognition of them makes the diagnosis infallible. The other 
half of all cases must be diagnosticated by chemical analysis, a 
means of examination which applies to nearly all cases. Suspicion 
may be excited in the first place by the situation of the tumor. 
Echinococci, unlike cysticerci, avoid muscular tissue, and come to be 
lodged as a rule in certain viscera, preferably in the liver, lungs, 
spleen, brain, eye (orbit, but not in the ball), and kidneys. The 
anatomical elements mentioned have been discovered in the faeces, 
vomited matter, urine, sputum, or in surface fluid from sponta- 
neously ruptured sacs, most commonly in the fluid withdrawn by 
aspiration. The growth of the tumor is slow, extending at times 
over periods of from ten to fifteen, exceptionally to fifty-five, years. 
Years of latency may follow the infection. It is not malignant, and 
is seldom painful ; its symptoms being produced mainly by pres- 
sure upon, and dislocation of, natural structures. The tumor, when 
it may be percussed, palpated, or grasped, is found to be elastic, 
with a sense of semi-fluctuation. It develops on palpation also a 
peculiar fremitus, the so-called hydatid purring — a sensation similar 
to that felt in stroking a cat, or striking the spiral spring of a sofa 
or a bass chord of the pianoforte, i Opinions differ as to the value of 
this so-called hydatid fremitus, which was first remarked by Brian- 
gon in 1828. Skoda claims that the same sensation is yielded 
by every sac with fluid contents and elastic walls. Cobbold does 
not think it different from the impulse communicated by fluid matter 
in any other kind of tumor. Bamberger, finding it in ascites and 
ovarian tumors, does not consider it characteristic. On the other 
hand, Heller and most French authors regard it as almost pathog- 
nomonic. Frerichs found it in but half his examinations. Tillaux 
maintains that it is caused by the impulse of daughter sacs upon 
each other in the absence of liquid in the parent sac. When the 
parent sac contains fluid in which the daughter sacs swim, there 
is no tremor. 

As already stated, chemistry furnishes the surest means of diag- 
nosis. The fluid is colorless, opalescent, neutral, and has a specific 
gravity of 1.005 to 1.015. Albumin is wanting, or is present in but 
very slight amount, although it begins to abound after frequent 
tappings. The test is satisfactorily made by heat or nitric acid. 
Common salt is abundant. A solution of the silver nitrate dis- 
tinctly precipitates the insoluble chloride. In doubtful cases there 
remain two other tests of almost equal value, viz. , the detection of 
succinic acid and inosite or muscle sugar. Both of these agents are 
found naturally in other organs of the body, but not in the liver ; 



EXTOZOA. 37 

hence the value of the evidence furnished by their presence in this 
organ. 

It need scarcely be stated that while the absence of succinic acid 
and inosite does not exclude echinococcus, the presence of them is 
strong evidence of its existence. In general, it may be said that the 
chemical tests are more valuable than the microscopic, though the 
latter are more positive when present. 

With all these means of recognition, the echinococcus cyst often 
escapes detection. Echinococcus of the brain may simulate typhoid 
fever ; in long bones it develops spontaneous fracture rather than 
tumor. Thierfelder states that but seven of thirteen cases were 
recognized during life at Rostock ; Briicke declares that but thirteen 
of twenty-two cases were discovered at the Berlin Charite ; and 
Madelung maintains that, as a rule, but one-third of all the cases are 
diagnosticated. Most of -these observations, however, antedate the 
days of aspiration, which has immensely simplified the examination. 

Echinococcus cysts are not amenable to relief by internal medi- 
cation. If further evidence than the failure of every kind of drug 
were necessary to prove this fact, it may be found in an observation 
of Leidy, who discovered in the body of an English sailor sent to 
him for dissection, the tissues having been thoroughly bleached by 
an injection of zinc chloride several days after death, a hydatid tu- 
mor of the size of the fist in the right iliac region, full of daughter 
cysts containing still living scolices. 

The most simple method of treatment of echinococcus cysts is by 
aspiration of their contents. Murchison reported, of forty-six cases 
thus treated, thirty-five successful results. In ten cases subsequent 
suppuration necessitated incision, whereby eight cases recovered and 
two died. The remaining case died of acute peritonitis in twenty- 
four hours. Fagg, Hilton, Durham, and Hand- 
held report nine cases cured by ' electrolysis. 
Jansen, of Iceland, still adheres to the plan of 
opening by the caustic method of Recamier. 
Loreta (1886) first successfully resected a large 
part of the left lobe of the liver stuffed with 
echinococci. Radical treatment demands lapa- 
rotomy incision and drainage under asepsis. 
Mudd successfully cut out an echinococcus cyst muiwocuiari? m ° C( 
protruding as a tumor from the brain. 

The rare form of degeneration known as the mult il ocular cyst 
was first differentiated from colloid cancer in 1856 by Virchow, who 
showed its parasitic nature. Vierordt, who has been able to collect 
in all seventy-nine cases, some of them antedating Tirchow's dis- 
closures, makes the curious discoverv that the disease is limited to a 




38 



ENTOZOA. 



very circumscribed geographical area. Of the seventy-nine cases y 
sixty-eight occurred in Wiirtemberg, Bavaria, and 
Switzerland, the rest in Baden, Austria, and Russia,, 
and one in the United States. Strange to relate, no 
case has ever been reported from the classic centres 
of Echinococcus hydatinosus, Iceland and Australia. 
All the victims were adults. The duration of the 
disease averages from one to two years, in one excep- 
tion eleven years. It is recognized by the anatomi- 
cal elements of the parasites, as in the other form of 
the disease. From its exogenous character there is 
no tendency to capsulation and no hope of securing 
its total extirpation ; hence the prognosis is, as yet 
tf/Mf at least, always fatal. Multilocular echinococcus is 
by no means to be confounded with exogenous hy- 
datid cysts, in which projections of brood capsules 
occur external to the parent membrane, penetrating 
the liver or other viscus at times in every direction. 
Such cysts are known as compound cysts, in distinc- 
tion from the multilocular cysts, which give to the 
organ invaded a honeycomb appearance. The prog- 
nosis of the compound or exogenous cyst is much 
more grave than that of the simple or endogenous 
cyst, on account of the inaccessibility of many, or 
most, of the growths. 



Round Worms. — Nematoid {vr/pia, a thread) 
worms are represented as pathogenic entozoa of the 
human body in the round worm, the threadworm, 
the anchylostoma, and the trichina spiralis. The 
order, higher in the scale of life than the cestodes, is 
characterized by an elongated, filiform body without 
circulatory or respiratory apparatus, but generally 
provided with an intestine open at both ends. The 
sexes are separate. 

The Round Worm, Ascaris lumbricoides — a slug- 
gish worm, inappropriately designated ascaris, as it 
is much less active than the threadworm ; surnamed 
lumbricoid, a lubricitate (Hooper), from its slipperi- 
ness; coarsely resembling the common earthworm, 
which seems to have been named for it — is the most 
common, as it is the most prolific, of all intestinal 
parasites. It is also found everywhere over the 
globe. It is cylindrical in shape, with pointed ends, pale red in 



Fig. 39.— Ascaris 
lumbricoides. 



EXTOZOA. 39 

color during life, paler than the common earthworm, pinkish -gray 
after death, averaging the diameter of a goose quill ; the female, 
measuring in length fifteen inches with a capacity of extension to 
twenty -four inches, is twice as long as the male. The head tapers to 
a point more gradually than the tail, which, in the male, is distin- 
guished by its direct incurvation to a hook-like process for grasping 
the female. A pair of white, delicate hairs, the protruding penis, are 
often visible on the ventral aspect near the tail; the vulvar opening 
is situated at the junction of the first and middle thirds of the body. 
The head is further characterized by three semicircular, knob-like 
projections about the triangular opening of the mouth, whereby it 
is readily distinguished from the earthworm, sometimes shown in 
attempted deception, which has a rounded head with the mouth 
under it in the form of a transverse slit. Vacuoles in the muscular 
mesh work of the skin give issue to a pale-red, oily, 
irritating matter of a peculiar odor, which is so /^^^ 
persistent as to remain with the worm after thor- 
ough washing, and communicate itself in time to 
alcohol in which these worms have been preserved. 
The bulk of the body is taken up by the genital 
apparatus, one female developing sixty-two million 
eggs. The ova, ^-q to T J-g- of an inch in diameter, 
provided with a thick, firm albuminous shell or 
envelope, of nodular surface, usually stained with 
bile, offer extraordinary resistance to destructive 
agents. Thus they may withstand desiccation for fig. 40. -Round worm: 
months, or remain a long time without in-jury to *' head from Slde ; 2 , 

' & . . ., from top; 3, tail of male. 

the embryo m alcohol, turpentine, chromic acid, 
etc., agents which quickly kill the mature worm. They are voided 
in quantity with the faeces, and may be counted by hundreds with a 
low power under the microscope in. a small mass of f eeces. 

Although Hippocrates was familiar with and described this para- 
site, the mode of development of the egg to the worm has been but 
recently determined. Impure drinking water has always been sup- 
posed to convey the parasite or its ova to the body of man ; and 
recent observations by Grassi, Lutz, and Leuckart confirm this 
view. Aside from impure water, the disease is conveyed by dirt, 
mud, sand contaminated with fseces, and but rarely and accidentally 
by food, as fruits and salads. Infection begins in childhood with 
the first attempts at walking, infants being comparatively exempt. 
It never prevails extensively, nor are numerous ascarides ever en- 
countered, in denizens of cities with good water supply. It is much 
more frequent in the country and small towns, and if most prevalent 
in the tropics, which seems to be the case, it is because of the greater 




40 ENTOZOA. 

neglect of the water supply. The insane, whose habits are notori- 
ously unclean (coprophagi), are infected as a rule. 

The round worm dwells in the small intestine, usually about the 
middle of it, lying stretched out in its course. But a single worm 
may be present, more commonly from four to six, more rarely great 
numbers. Cruveilhier once counted a thousand. They cannot live 
in the stomach or colon, and, when found in either place, are in 
process of extrusion. They have no power of effecting perforation, 
but may migrate into natural openings in the intestinal canal, as into 
the gall ducts, pancreatic ducts, vermiform appendix, or, during the 
act of vomiting, into the larynx — where they have caused fatal suffo- 
cation — bronchi, nares, and thence into the tear ducts and into the 
Eustachian tubes, whence they may escape, through a previous 
perforation of the drum membrane, into the external ear. Thus 
Kartulis found, in a fatal case, one hundred and twenty in the small 
intestine, twenty in the large intestine, twenty in the stomach, three 
in the common bile ducts, three in the hepatic duct, five in the gall 
bladder, and sixty in the liver — all in the liver the seat of abscesses. 
Most of the migrations occur, however, after the death of their host. 
Such massive accumulations as to cause more or less complete occlu- 
sion of the intestine are also for the most part, though not always, 
post-mortem phenomena. Escape into the peritoneal cavity presup- 
poses a perforation of the intestine, as from typhoid fever, tubercu- 
losis, etc. So, also, worm abscesses, accumulations of pus containing 
worms, occur at the site of hernise, at the umbilicus in childhood, in 
the groin in adults. Incarcerated with other contents of the bowel, 
the worm escapes through some perforation in its wall, the result of 
an inflammation to the cause of which the worm may possibly con- 
tribute chemically; as Huber noticed in himself, after handling these 
worms, itching of the head and neck, wheal-like formations on the 
skin, swelling of the ear, conjunctivitis, and chemosis. It is observed 
also that worm abscesses speedily heal after evacuation of the pus 
and discharge of the worm. 

Symptoms. — Round worms frequently exist in the body without 
symptoms. In Grasses case a boy aged seven voided, two months 
after taking a pill containing one hundred and fifty ova, one hundred 
and forty-three mature worms, showing meanwhile no symptoms 
whatever. The discharge of the worm is thus often the first and 
only sign of its presence. It is often an independent catarrh of the 
intestine which sickens and discharges the worm, so that, as Kuch- 
enmeister remarks, ' ' host and guest agree very well together " as a 
rule. On the other hand, there may be due to the worm dyspeptic 
manifestations, anorexia, heartburn, colic, constipation or diar- 
rhoea, with puffiness of the eyelids, discoloration about the eyes, 



ENTOZOA. 41 

itching of the nose and amis, etc. The symptoms are wholly due 
"to local irritations, which display the same symptoms from any 
•cause. Various nervous disorders, paresthesia, chorea, epilepsy, 
have been attributed to these worms, but, as in the case of tape- 
worms, without foundation as a rule. Disappearance of the symp- 
toms with extrusion of the worm would be the only proof of such 
•dependence. 

The diagnosis rests, as has been said, presumptively upon the 
discharge of one worm, when others may be supposed to exist ; or 
upon the discovery of ova in the feces, which infallibly indicates the 
•continued presence of the worm in the bowel. All other symptoms 
are fallacious. 

Prophylaxis. — A supply of pure water is the best preventive. 
.So long as doubt pertains to drinking water the precaution should be 
taken to filter it properly. The ova of no intestinal parasite will pass 
through a filter of porous clay. Children should be kept out of the 
dirt, or at least some care should be exercised regarding the source 
of the sand and dirt in which they play. They should be taught not 
"to taste the "mud pies " they make. 

Treatment. — Santonin is the best parasiticide. It is best admin- 
istered in doses of from two to five grains suspended in castor oil, 
as it kills, but does not expel, the worm ; or in capsule, compressed 
disc, troche, or powder with sugar of milk, equal quantity, fol- 
lowed by a dose of castor oil 3 i.- 3 i., or calomel gr. ij.-v. It 
should be given at night, every night or every other night, three 
times, that the patient be not disturbed by the blue or yellow vision 
which it sometimes occasions. Transitory dysuria, incontinence of 
urine, and, in very nervous subjects, even light delirium, rarely en- 
sue. Where this remedy would seem to be contra-indicated it may 
be best substituted by thymol, one to two drachms, in divided doses 
.given in quick succession, and followed by wine, whiskey, or brandy 
to counteract any depressing effects. 

Threadworm. — Oxyuris (ogvz, sharp, ovpa, tail, characteristic 
•only of the female) vermicularis, from its size and shape ; the 
thread, pin, from its situation, seat ; or from its activity, spring 
worm, is found only in the lower part of the large intestine of man, 
in which it spends its whole existence. The female, two-fifths of an 
inch in length, is readily recognized by its long, awl-like, slightly 
wavy tail and chalky -white color, the color of the eggs with which 
the body is stuffed appearing through its translucent envelope or 
;skin. The orifice of the vulva is near the middle of the body. The 
male measures but one-tenth of an inch, is blunt at both ends, and 
incurvated at the tail for grasp of the female. The penis consists of 
■a single spiculum, often seen projecting near the tail. Males, rare 



42 



ENTOZOA. 



in number and small in size, were for a long time overlooked, and. 
are best discovered in scrapings of the intestinal mucus. The hab- 
itat of the threadworm is the caecum, and not the rectum as is com- 
monly believed. Ignorance of this fact accounts for the frequent 
failure of treatment. Threadworms are ubi- 
quitous, occur at all ages, but are more fre- 
quent among the poor and unclean, and espe- 
cially among children. Young worms begin to> 
pass from the rectum in fourteen days after 
ingestion of the ova ; and as each female may 
give issue to successive crops, though the dura- 
tion of individual life is short, the progeny is 
maintained often throughout the life of the host. 
The eggs, t1 l_ X ygVo mcn m diameter, are 
oval and plano-convex. The embryo develops 
rapidly, in from four to six hours, so that the 
whole process may be easily followed up with 
the microscope. The myriad ova and rapid de- 
velopment render self-infection almost unavoid- 
able. In fact, ova are always to be found in- 
sinuated (by scratching) under the ringer nails 
of infected individuals. Helminthologists be- 
come infected in handling the worms. 

Threadworms, though active in movement, 
have little power of migration over a dry sur- - 
face, perishing rapidly after leaving the bowel ; hence infection from 
contact, as from a bedfellow who happens to be the host of worms, 
cannot occur. The introduction of ripe ova from an infected indi- 
vidual into the stomach is an essential factor in etio- 
logy. Infected mothers, nurses, cooks, waiters, etc., 
generally convey the ova. Biting the nails is a not 
uncommon mode of reinfection. Orphan and in- 
sane asylums furnish all the prerequisites for rapid 
dissemination. 

Symptoms. — So long as the parasite remains 
above the rectum it gives rise to no symptoms. De- 
scent of the mature female into the rectum to dis- 
charge its ova and escape at the anus — which occurs 
most frequently at night, on account of the quiet of the body at night 
and the greater warmth of the bed— is attended with itching, bor- 
ing, burning sensations, which may become so intolerable as to 
prevent sleep and lead thereby to nervous distress. Migration into • 
the vagina extends the surface of irritation, and may induce pruri- 
tus, masturbation, and nymphomania. It is questionable if the-- 




Female 
with ova. 
Oxyuris vermi- 




Fig. 42. — Oxyuris 
vermicularis, natural 
size; one female, two 
males. 



ENTOZOA. 43 

worm ever finds its way beneath the prepuce or into the male 
urethra, though it may be carried thither by the fingers. The in- 
tense irritation about the perineum, with manipulations for its relief, 
may of themselves excite the genital apparatus and thus lead to a 
train of nervous disorders. 

Diagnosis. — Direct inspection of the anus, more especially after 
the use of an enema, discloses oxyurides in numbers, so that a search 
for the ova is generally superfluous. The ova may, however, always 
be found, in the absence of visible worms, in scrapings of the upper 
parts of the anus, as everted in defecation, upon paper used in wip- 
mg, or in its uppermost parts accessible to the handle of a scalpel or 
the eye of a catheter. Vix declares that he never found a single 
case where the eggs were not visible in countless numbers in the 
first field of vision. The detection of the worm or its ova, it is need- 
less to state, affords the only positive diagnosis. 

Prophylaxis. — Scrupulous cleanliness on the part of those af- 
fected, regular ablutions before meals, and the frequent use of the 
nail brush, are preventive measures of importance. Children cannot 
be prevented from putting their own fingers in their mouths, but 
surely the filthy habit might be stopped of inserting those of their 
attendants. The bad habit of biting the nails can be broken up. 
After all, the only real prophylaxis is the speedy evacuation of every 
member of the colony in affected individuals. 

Treatment. — Though some degree of moisture is necessary to the 
growth and reproduction of the threadworm, it cannot live in water, 
which causes it to swell up and burst. Hence the administration of 
anthelmintics is unnecessary and, because of the distance of the 
worms from the mouth, inefficacious. Heller saw oxyurides creeping 
about ' ' quite lively " under strong solutions of carbolic acid applied 
as a dressing to condylomata of the perineum. Inundation and 
maceration with water, if practised effectively, suffice to destroy and 
remove them. Simple as it may seem to accomplish it, the treat- 
ment is nevertheless seldom successful. Failure is due to the fact 
that the applications are limited to the rectum. Irrigation with soap 
and water, because less irritant to the bowels than simple water, by 
means of a long rectal tube or catheter in the knee-elbow posture, 
best dislodges and discharges these worms. Irrigation with luke- 
warm water, two to four quarts, should precede the injection of the 
same quantity of soap water, and the operation should be repeated at 
intervals of one or two weeks, at least three times, that subsequent 
broods, previously secreted in the sacculi of the intestine or vermi- 
form appendix, may be successively attacked. Ammoniated mercu- 
rial ointment best relieves subsequent itching and irritation about the 
perineum. 



44 






ENTOZOA. 




Whipworm. — Trichocephalus dispar (6 pig, rpz^-o^ hair, xecpaX??, 
head; dispar, unequal), male one and a quarter, female two inches in 
length ; is readily recognized by the inequality of its thickness, the 
head extremity constituting a long, spirally turned thread, the lash ; 
the body a much stouter, shorter mass, the handle of the whip ; 
habitat, the caecum and its vicinity. The brownish-colored eggs, 

0.05 X 0.02 mm., which are not infrequently 
voided in the stools, are differentiated from 
those of other nematoids by their double 
contour, strongly granulated yolk, and dis- 
tinct lemon shape, which is more closely 
simulated at both (flattened) poles by pro- 
jecting (shining) coverlets. The eggs are 
developed into mature worms in the body 
of man. The whipworm, which may furnish one and a half million 
eggs in twenty-four hours, indicating the presence of nine hundred to 
fifteen hundred parasites, is, according to Moosbriigger and Leich- 
tenstern, a frequent cause of anaemia and blood-stained diarrhoea 
in children. 

ANCHYLOSTOMA (a'yxv\o$ Gropia, fixed mouth) DUODENALIS ■ 
Gothard worm, from the number of cases (over one thousand reported) 
among the workmen in the excavation of this tunnel. — A thick, red, 



Fig. 43. 
and male 



Whipworm, female 




Fig. 44.— Eggs of entozoa: 1, 
4, Taeniasagiaata; 5, Taenia lata; 6 
bricoides. 



Distoma hepaticum; 2, Distoma lanceolatum ; 3, Taenia solium ; 
Oxyuris vermicularis; ?, Trichocephalus dispar; 8, Ascaris lum- 



round worm, female one-half to three-quarters of an inch long, male 
half as long ; it is distinguished by an open, oval stoma, lined with 
teeth, by means of which it attaches itself by hundreds and thousands 
to the duodenum and jejunum, penetrating even to the submucous 
tissue, where it sucks itself, like a leech, full of blood. It is found 
in Egypt, parts of Europe, South America, and Africa, whence it 
was imported by slaves into our own Southern States, Louisiana, 
Alabama, and Georgia. The oval ova, 0.05 mm. long, are voided in 



ENTOZOA. 



45 




1, male: 2, female 
% natural size. 
Fig. 45 



, magnified head, 
showing teeth. 
Anchylostomum duodenale. 



the intestines to be discharged with the faeces and continue their 
growth in stagnant water, whence they are received into the intes- 
tine of man, in which development is completed. 

The symptoms, which show themselves in acute and chronic 
forms of anchylostomiasis, depend mainly upon loss of blood. The 
disease is announced in both forms with pain in the stomach and 
intestines, to be followed by anosmia and chlorosis. The lips and 
finger nails become pale, the pulse is increased in frequency, and in 
chronic forms there is either marked hypertrophy and dilatation of 
the heart or disturbance of valvular ac- 
tion. In the last stages of the disease 
anosmia becomes profound and oedema 
begins to show itself about the ankles 
and legs. Fatty degeneration of the 
heart, with stasis, cyanosis, and 
dropsy, gradually supervenes in the 
cases of more protracted course. 

The symptoms may simulate, and 
have been mistaken for, catarrh, ulcer, 
and cancer of the stomach, chlorosis, 
anaemia, pernicious anaemia, leukaemia, 
valvular disease of the heart, and malarial cachexia. The diagnosis 
rests upon the fact of multitudinous attack, by preference of the 
working classes, masons, and miners, without regard to age and sex, 
but with especial regard to a hot climate and bad drinking water.. 
Malaria is differentiated by enlargement of the spleen and liver, 
melanaemia, and characteristic corpuscles in the blood ; leukaemia, 
by affection of the spleen and lymph glands, with specific altera- 
tions in the blood. Certain cases of pernicious anaemia are cases of 
this disease. In doubtful cases the diagnosis is established by the 
detection of ova in the stools, generally intimately intermixed with 
the contents of the bowel on account of the high habitat of the worm. 
They are best disclosed by dilution of the faeces in water, and exami- 
nation of the sediment which falls over night in a conical glass. 

Treatment. — Thymol has proven, in the hands of Bozzolo, Grazi- 
adei, and Lutz, a specific in the treatment of this hitherto intractable 
disease. The treatment should be prefaced with a dose of calomel, 
gr. x., and the drug should be given in repeated moderate doses, 3 i. 
pro die in capsule or compressed tablet, for several days. Large doses 
of the fluid extract of male fern, 3 ij.-vi., if fresh and of good quality, 
are almost equally effective. 

Trichina {dpi£, rpixot, hair) spiralis (a name applied by Owen, 
1835, to the immature parasite encapsulated in muscle, where it 
was first observed) is present in man in both the developed and 



46 ENTOZOA. 

undeveloped states : developed, mature in the intestinal canal ; un- 
developed, immature in the muscles. The trichina also infests the 
hog, rat, cat, rabbit, fox, and guinea-pig. It is a pure parasite, the 
;sole example among the entozoa, having lost all relation with the 
external world. 

The history of the trichina is wholly modern. Calcified remnants 
of this parasite in muscle were looked upon as dissecting-room curi- 
osities up to 1835, when Paget took a specimen to Owen, who gave 
it the very appropriate name it bears. Leidy, in 1846, discovered 
in a piece of ham upon his plate the same immature form, which 
was still regarded as an innocent wandering nematoid worm until 
1860, when Zenker discovered it in myriads in the muscles of a 
patient who had died of a disease diagnosticated as typhoid fever, 
but marked by extreme pain in the muscles, with oedema of the 
surface, which symptoms he correctly attributed to the presence 
of the parasites. Virchow, Leuckart, and Zenker then demonstrated 
their migration from the intestines to the muscles ; and two years 





Fig. 46. Fig. 47. 

Figs. 46 and 47.— Mature trichinae. 

later, in 1862, Friedreich made the first diagnosis of the disease in 
life, with the detection of the parasite in a piece of exsected muscle. 

Anatomy, etc. — The mature intestinal trichina is round, elon- 
gated, white, and, as its name implies, extremely filiform, on which 
account it is barely visible to the naked eye as a fine wool hair or 
silvery thread. The head, formerly regarded as the tail, is drawn 
out almost to a line, while the caudal extremity is somewhat rounded 
off and is not much thinner than the body. The alimentary canal 
begins with a muscular mouth, is continued into an elongated oeso- 
phagus, expanding into a flask-shaped stomach, to be again con- 
tinued into the intestinal canal, which at its extremity receives in the 
male the opening of the seminal duct, arising from a single testicle, 
a thick cul-de-sac which runs along the side of the body. The 
female, one-eighth of an inch in length, is twice as long as the male 
to accommodate the ova with which it is stuffed, and which are 
hatched within the body and born alive. The orifice of the vagina 
is situated at the junction of the first and second quarters of the 
body. Each female may give birth, in the course of a month, to 
over a thousand young. The parent trichinae are short-lived. They 



ENTOZOA. 



47 







are probably, for the most part, digested and absorbed after repro- 
duction, as they disappear from the intestine in five to eight weeks, 
and are, unfortunately, not often to be found in the stools. 

The new-born immature trichinae, one two-hundredth of a line in 
length, having escaped from the body of the parent, penetrate the 
intestinal wall, probably by 

means of chemical irritation, M>"' $ % ?) f^^ 

to migrate, chiefly along the >ifc £[ V^HI 

meshes of the connective tissue, 
to contiguous muscles, more 
especially to the diaphragm, 
abdominal, intercostal, laryn- 
geal, cervical, ocular, and 
proximal muscles of the ex- 
tremities, in which latter re- 
gion they are crowded, as if 
arrested, at the tendinous ex- 
tremities. Here they continue 
to grow for fourteen days to a 
length of half a line, when 
they coil up to assume the well- 
known spiral form, disinte- 
grating the muscular tissue, 
expanding and thickening the 
sarcolemma, and, as a result 
of the inflammatory process 
thus produced, leading to the 
formation of a lemon-shaped 
capsule one-fifth of a line in 
length, in which they lie for the most part singly, or more rarely in 
groups of two, three, or even four. Thus they remain encysted alive 
for a year or more, exceptionally as long as twenty-five years, or 
become subsequently calcified — after calcification of the containing 
capsule — a process which begins at the poles of the cyst, but is not of 
necessity fatal to its contents, even when complete. 

Muscular tissue thus infested, when taken as food (one ounce con- 
taining at times fifty to one hundred thousand parasites), is dis- 
solved in the process of digestion, liberating from their capsules, 
in from three hours to three days, the muscle trichinae, which attain 
sexual maturity in the intestinal canal in five days, and then re- 
produce their species with the rapidity described. Trichinae have 
also been found in the blood, mesenteric glands, and peritoneal cavity. 

Thus the Trichina spiralis, which was formerly regarded as an 
accidental and innocent inhabitant of the muscular tissue, has been 



Fig. 48. 



-Young trichinae in muscle. 



48 



ENTOZOA. 



unmasked, since the first observation of Zenker in 1860 on a servant 
girl in the hospital at Dresden, as one of the most widely dissemi- 
nated and deadly of all known parasites. 

The symptoms of trichinosis, as the disease is called, vary ac- 
cording to the quantity ingested and the irritation produced. Small 
numbers produce no symptoms, calcified remnants having been 
often found in autopsies with a history of absence of any symptoms 





Fig. 49.— Trichina encapsulated in muscle. 



Fig. 50.— Calcified relics. 



in life. A certain stage of development and capsulation is also re- 
quisite to infection. Too young or insufficiently protected trichinae 
are killed in the stomach. Calcified capsules may not liberate their 
contents. The irritation, with the consequent rapid increase of peri- 
stalsis in childhood, often causes the expulsion of trichinae unlibe- 
rated from their capsules in the stools. The ingestion of alcohol in 
large quantities with the meal may destroy them as rapidly as they 
are liberated. 





Fig. 51.— Young trichina liberated from capsule. 



Fig. 52.— Encapsulated trichina. 



The stage of invasion, which shows itself in from three hours to 
three days or longer, as successive quantities may be ingested, is cha- 
racterized by irritation on the part of the stomach and intestines, viz., 
by anorexia, nausea, vomiting, tenderness to pressure, pain in the 
boivels, and diarrhoea. These symptoms may be absent altogether, 
or may vary greatly in intensity, to assume at times such severity 
as to be mistaken for cholera, as in the epidemic of Hedersleben in 
1865, a city of two thousand inhabitants, where three hundred and 
thirty-seven persons were attacked, and one hundred and one died, 



ENTOZOA. 49 

three on the sixth day. Animals fed with trichinotic flesh often 
succumb on the fourth day. The fever, thirst, headache, and gene- 
ral prostration which may accompany the local signs belong equally 
to other causes of intestinal irritation and are not peculiar to trichi- 
nosis. 

Characteristic symptoms announce the advent of the stage of 
migration and colonization in the muscles, which begins as a rule 
on the seventh day with oedema, functional disturbance, and pain 
in the muscles. (Edema shows itself first, or is noticed first as a 
rule, in the eyelids, disappearing in a few days and returning later 
in the course of the disease. This oedema is often coincident with 
pain, tension, and restriction of movement in the muscles of the 
eyes, as evidence of early invasion of these muscles ; though the pre- 
sence of oedema here as elsewhere, in the absence of muscular signs, 
has also been ascribed to the action of some toxic principle acting 
upon the vaso -motor system. CEdema of the face is often, that of 
the hands and feet more rarely, associated with that of the eyelids. 
Pronounced oedema of the skin over the affected muscles occurs 
even more constantly than about the face — is absent, in fact, in only 
ten per cent of cases. This cutaneous oedema also disappears for 
a few days, to return later. It is distinguished from the oedema 
of heart and kidney disease by its association with the muscular 
signs, as well as by the fact that it spares the genital organs, the 
scrotum and labia major a. 

Muscle symptoms appear on the ninth or tenth day as a rule, de- 
layed at times to the fourteenth, varying in every grade of intensity 
from lassitude, stiffness, or tension, to board-like indurations and 
most atrocious pains. The flexors of the extremities, the biceps and 
muscles of the calf especially, become swollen, tense, and tender, 
the extremities being held in semi-flexion to simulate the postures 
of acute articular rheumatism. Invasion of the diaphragm, abdo- 
minal and intercostal muscles, gives rise to dyspnoea ; invasion of 
the masseters, which may excite trismus, renders mastication pain- 
ful or impossible ; while invasion of the tongue and pharyngeal 
muscles may restrict or prevent deglutition, accounting thus for the 
rapid emaciation. Invasion of the larynx is shown by hoarseness of 
voice or aphonia in twenty per cent of cases, and of the ocular mus- 
cles by fixation of the eyeball, chemosis, and occasionally by mydri- 
asis and nystagmus. Impairment of hearing follows invasion of 
the stapedius muscle. 

Siveating is another common symptom of trichinosis. It occurs 
early, always in connection with the muscular pains, and is profuse 
and distressing in correspondence with their severity. It is often 
attended with miliaria, occasionally with herpes. Pustular erup- 



50 ENTOZOA. " 

tions — Friedreich once found a free trichina in a pustule — acne, f urun- 
culosis, may follow the disappearing oedema of the face. 

Still another quite common as well as obstinate symptom is in- 
somnia, which often rapidly exhausts the patient. With this excep- 
tion the nervous system shows no symptoms. Though most cases 
are characterized by apathy or depression, the brain remains clear, 
except in the last stages of the severe attacks, when somnolence, 
stupor, or delirium may for a short time precede the end. 

Fever does not belong of necessity to trichinosis. Average cases 
show slight elevations of temperature, up to 104° F. in the severe 
forms, which at times present the course of remittent, or more fre- 
quently of typhoid, curves. Bronchitis, even catarrhal pneumonia, 
may result from the impeded respiration, while extensive, even fatal 
hypostatic pneumonia from prolonged decubitus is not uncommon in 
protracted cases. 

Duration. — The disease lasts from two weeks in the lightest 
cases to eight weeks in pronounced cases, and with sequelae, for the 
greater part of a year, in the severest forms. Kunze heard com- 
plaints of rheumatic pains in bad weather four years after the He- 

dersleben epidemic, and Kratz found 
weakness of the muscles in one case 
eight years after the attack. The mor- 
tality ranges from one to seventy, 
averaging thirty per cent. . Death oc- 
rrichina in muscle. curs usually from exhaustion or blood 

poisoning in from four to six weeks, ex- 
ceptionally earlier from gastro-intestinal irritation, and later from 
hypostatic pneumonia and marasmus. 

The prognosis depends largely upon the number ingested and 
the lapse of time. Children almost never succumb, because most of 
the trichinae are ejected by diarrhoea. Patients who survive the 
eighth week recover. Severe myositis or dyspnoea, profound pros- 
tration and nervous symptoms, aggravate the prognosis. Recovery 
is, as a rule, much more tedious and protracted than after other 
acute infections of corresponding severity. 

The diagnosis is illuminated often by the fact that others are 
simultaneously affected, or by the inspection of suspected pork ; 
possibly by the detection of mature or encapsulated trichinae, more 
especially after a brisk cathartic, in the mucous but not in the fluid 
contents of the voided stools ; positively by the discovery of imma- 
ture trichinae in the muscles, extracted preferably after linear inci- 
sion under antisepsis, from the deltoid or lower part of the biceps 
muscles — for the most part an unnecessary procedure. A history of 
gastro-intestinal irritation, followed by constipation, oedema of the 







EXTOZOA. 51 

face on the eighth day, and muscle signs by the tenth day. with 
sweating, insomnia, headache, thirst, and fever, sufficiently charac- 
terizes the disease. 

Articular rheumatism, which has pain and sweating in common 
with trichinosis, is distinguished by the affection of the joints proper, 
more especially of the smaller joints, by the absence of gastro-iutes- 
tinal irritation, dyspnoea, insomnia, and affection of the muscles of 
the jaws and eyes. 

Muscular rheumatism selects by preference other muscles than 
those affected in trichinosis, and is unattended with gastrointes- 
tinal irritation, oedema, fever, and sweats. Grawitz, Virchow's as- 
sistant, declares that trichinae were found, on autopsy, in one-third 
of the cases of so-called muscular rheumatism. 

Typhoid fever is differentiated by the mental disturbance, a char- 
acteristic temperature curve, diarrhoea generally throughout the dis- 
ease, meteorism, and is not attended with oedema, asthma, and mus- 
cular signs. 

Meningitis shows herpes as a rule, hyperaesthesia, opisthotonos, 
a contracted abdomen, and has a different history. Finally, poly- 
myositis, which shows pain in the muscles, tension, deformity, pros- 
tration, oedema, sweats, and insomnia — in short, most of the signs 
of trichinosis — is distinguished by isolated attack, by the absence of 
history and gastro-intestinal signs, preference of the extensor mus- 
cles, and exemption of the diaphragm, larynx, tongue, and pharynx. 
Excised portions of muscle show hyaline or waxy degeneration, but 
no trichinae. 

Prophylaxis. — Xaked-eye inspection of meat does not disclose 
the Trichina spiralis except in cases of calcification, and calcification 
is not necessarily fatal to the trichinae. Putrefaction does not de- 
stroy them. Copious libations of alcohol with meals is a preventive 
as unreliable as unadvisable. Smoking and pickling, as ordinarily 
practised, kill only the surface trichinae. A temperature of 160° F. 
is fatal to the trichina, so that thorough cooking of meat offers a 
sure prevention of infection. A long subjection to high temperature 
is requisite to secure penetration to the interior of a large mass of 
meat of the necessary grade of heat. 

Therapy. — Successful therapy depends upon an early diagnosis, 
which is often unattainable. A brisk cathartic, calomel gr. x.-xx., 
castor-oil § i. , or infusion of senna, followed by irrigation of the 
colon, offers a hope of discharging many of the worms before the}' 
have been liberated from their capsules ; and inasmuch as Kratz 
and Cohnheim found trichinae in the stools as late as the twelfth 
week, it may be said that it is never too early or too late, for pur- 
poses either of diagnosis or of therapy, to give this method trial. 



52 ENTOZOA. 

Recently liberated trichinae may be benumbed and more readily dis- 
charged by the administration of thymol, 3 i.-iss., divided in two or 
three doses ; or extract of male fern, 3 i.-iv. After colonization in 
the muscles the treatment becomes purely symptomatic. The hope 
of radical extermination by rapidly diffusible agents, picric acid 
and benzin, or water-extracting agents, glycerin and alcohol, has 
proven illusory. Applications of hot water, salicylic acid gr. vij., 
salol gr. x., more especially phenacetin gr. x., or antipyrin gr. v., 
every hour, may be tried in relief of pain not so great as to indicate 
morphine, which becomes a necessity in severer cases. Sodium 
bromide gr. xl., antipyrin gr. x., chloral gr. xv., may suffice to se- 
cure sleep, which is, however, in bad cases forced only by morphine. 
As the safety of the patient depends upon speedy encystment of the 
trichinae — a process which is hindered by motion of every kind — re- 
pose and quiet as absolute as possible should be enjoined and se- 
cured. The strength is to be sustained by alcohol and food until 
the force of the disease is spent. 




Fig. 54.— Guinea worm. 



Filaria Medinensis (Guinea worm). — Found frequently in Asia 
and Africa. A very long — sixty to one hundred centimetres — slender 
worm with rounded head and hooked tail ; female only known as 
yet, which finds some median host in minute Crustacea, with which, 
in drinking water, the embryo gets entrance into the body of man. 
It is carried by the blood vessels to the periphery, where it develops 
to maturity, forming furuncles and abscesses in the subcutaneous 
tissue, most frequently in the lower extremity near the heel. In this 
process it may develop gangrene or general rigors, fever, convul- 
sions, etc. Care must be taken in its extraction not to break it off, 
as it may protrude from an open wound in the skin. To avoid this 
accident it should be gently wound around a stick and very slowly 
withdrawn in the course, if necessary, of several hours. 

Filaria Sanguinis. — A dangerous nematoid worm found in the 
body is the Filaria sanguinis, first described by Bancroft, hence 
Filaria Bancrofti, and first recognized as a cause of chyluria by 
Wucherer, of Bahia (1869). 

The Filaria sanguinis, like the Trichina spiralis, is found in both 
mature and immature states in the body of man. The mature form 



ENTOZOA. 



53 



lives viviparous in the lymph vessels of the scrotum and the lower 
extremities, and is a parasite of the respectable length of eight to ten 
centimetres. The young filarise find their way from the lymph ves- 
sels to the blood, where they are encountered in great 
numbers, each worm measuring 0.35 mm. in length, 
with a breadth about the diameter of a red blood cor- 
puscle. A protruding sheath often envelops one end of 
it. The worm shows active sinuous motion. Manson 
made the curious discovery that the filarise of the blood 
are to be seen only at night, whence the failure which 
has marked many attempts at their discovery during 
the day. Fluids must also be examined fresh. Some 
intermediate stage of development must exist between 
the mature filaria in the lymph vessels and the imma- 
ture filaria in the blood, outside the body, else various 
transition forms would be seen. There is reason to be- 
lieve that the animal or insect which officiates in secur- 
ing this transition state is the mosquito. The mosquito 
sucks itself full of blood containing the filaria and carries 
it to water, whence the mosquito arises, so that the body of man be- 
comes the host of the work through the medium of drinking water. 




Fig. 55.— Filaria 
sanguinis. 




Fig. 56.— Filariae in blood vessels. 




Fig. 57.— Elephantiasis cruris lym- 
phangiectatica (Ziegler). 



The Filaria sanguinis is a dangerous parasite, in that it produces 
symptoms in both stages of development. In the skin it causes 



54 



ENTOZOA. 



sclerosis, elephantiasis, occlusions of the lymph vessels, lymphan- 
gitis, lymphangiectasis, and ruptures. In the blood and lymph ves- 
sels it may lead to occlusions, dilatations, and ruptures, with escape 
of lymph, sometimes of blood. 

The curious condition known as chyluria, from rupture of lymph 
vessels into the bladder or renal pelvis, is found to depend in many 
cases upon the Filaria sanguinis. The urine in these cases looks like 
milk, and may contain as much as three per cent of fat. Haematuria 
also, but more infrequently, arises from the same cause. 

Prophylaxis is simple. It consists in thorough boiling of all 
drinking water, from whatever source. Perfect filtration would be 
equally effective. 

]STo known remedy may reach this parasite in the tissues or in the 
blood. It has been suggested that the picro-nitrate of potash, on 
account of its highly diffusible properties, might be of benefit. Treat- 
ment is really wholly symptomatic. The tincture of iron is indicated, 
gtt. xxx. ter in die. Lewis recommended gallic acid. 




Fig. 58.— Liver fluke. 



Liver Fluke. — Of the trematoid {rpr/fia, foramen) worms, the 
only example of particular interest to the practitioner of medicine is 
the Distoma (double mouth) hepaticum, or liver fluke. The liver 
fluke is, as the name implies, a flat, somewhat triangular worm about 
an inch long and half an inch wide. The somewhat elongated head 
terminates, or begins, in an oval sucker, below which on the ventral 
aspect is another sucker, which orifices have given the worm its 
place. Between the two suckers is the genital orifice. The yellow- 
ish, oval eggs are among the largest found in the faeces. 

The liver fluke is encountered rarely in man, more frequently in 
the ox, deer, occasionally in the horse and hog, by far mOst fre- 
quently of all in the sheep, where it causes the disease commonly 
known as the rot, which kills annually thousands of sheep. 

The development of the liver fluke is a strange story. The eggs 
escape with the bile into the intestine, whence they eventually reach 



ENTOZOA. 55 

water, and, being provided with a ciliated envelope, swim about freely 
until they come in contact with the body of a snail, which they pene- 
trate to become lodged in its interior. Here the embryo, losing its 
ciliated envelope, becomes converted into a cyst, which produces on 
its interior elongated bodies called nurses. The nurses penetrate to 
the liver of the snail, where are developed neAv forms somewhat of the 
shape of the parent fluke, called cercarias. The cercarias escape from 
the nurse and the body of the snail into the water, and, being pro- 
vided with a long tail like a tadpole, swim about actively for a time 
until they become attached to subaqueous grasses, when they lose 
the tail and become quiescent. Thence, in the grazing of sheep, they 
may be reconveyed to their bodies to find a way to the liver and 
develop to sexual maturity. 




Fig. 59.— Distonia haematobium with ova. Male in gyneecophoric canal of female. 

The liver fluke is rarely found in the body of man in such num- 
bers as to cause occlusion, dilatation of the bile ducts, and reabsorp- 
tion of the bile, with the serious complications which result from this 
condition. The paucity of their number in man protects him against 
disastrous consequences. Prevention is the avoidance of subaqueous 
vegetables, such as watercresses, to which the bodies of snails are 
attached, and of impure drinking water. 

The Distoma Haematobium is found in the portal vein, in its 
trunk and derivative branches, in the body of men and apes. The ova, 
deposited in the mucosa of the ureters, bladder, etc., develop em- 
bryos which produce ulceration in these structures. This parasite 
is frequent in Egypt and Abyssinia, but has not been seen elsewhere. 



OHAPTEE III. 

BACTERIA. 

The term bacteria (fiaxrpov, a rod) applies collectively to a 
large* class of micro-organisms, the study of which is known as 
bacteriology. These bodies constitute the simplest and lowest forms 
of all living things. From their mode of propagation — by fission 
— they fall in botanical classification under the division of schizo- 
mycetes (<?xi& lv , to split). Bacteria are collections of protoplasm 
made up of an albuminose body, microprotein, fat, salts, and water. 
They have no chlorophyll, and may not, therefore, appropriate for 
their nutrition carbonic 'acid. Hence they must live as parasites 
on preformed combinations, but the smallest traces of nutritious 
matter — that which may be found, for instance, in the purest dis- 
tilled water — may abundantly suffice for their nutrition. They flour- 
ish best, as a rule, on feebly alkaline soils. With all other forms 
of life, they originate only from themselves, and never by spontane- 
ous generation. 

The body of the bacterium consists of the protoplasm (mostly 
colorless), enclosed in a delicate but resistant membrane, like cel- 
lulose, insoluble in acids and alkalies. This membrane may, under 
certain circumstances, swell to form a sheath or capsule, or exude a 
mucoid-like substance in which masses of bacteria may be agglome- 
rated to constitute the so-called zooglcea. Such zooglcea, in masses or 
lines, show definite shapes in definite soils, and furnish distinguish- 
ing characteristics. 

Bacteria are divided, from their shape, into micrococci, bacilli, 
and spirilla — i.e., spherules and cylinders, straight or curved. 

Micrococci occur alone as monococci, in pairs as diplococci, in 
fours in a single plane as merista, and in eights as sarcinse, which 
multiply in the three dimensions of space, to appear like dice. Mi- 
crococci multiplying in a line are known as streptococci (arps7tro?, a 
chain) ; multiplying in a mass, as staphylococci (araq>v\rf, a bunch 
of grapes). A coccus or bacterium whose length is greater than its 
diameter — i.e., an oval micrococcus — is a bacillus. Spirilla are 
curved bacteria — with one curve, like a comma, the vibrio ; or with 



BACTERIA. 



57 




Fig. 60.— Bacilli stained to show vibratile cilia and flagella (after Zettnow) 



58 



BACTERIA. 



successive curves, like a corkscrew, the spirochsete. Bacteria vary 
greatly in both length and breadth, but are, for the most part, so- 
small as to be on the confines of the visible, even with the micro- 
scope. 

The mass of micro-organisms are innocent to man. The bacteria 




Fig. 61.— Streptococcus. 



Fig. 62.— Spirochetes of relapsing fever. 



of putrefaction return to earth and air everything that has ceased to- 
live, so that life would soon become impossible without them. It is 
only under certain circumstances that the bacteria of putrefaction 
may prove injurious. Innocent micro-organisms injected into the 
body, even in mass, do no harm. They fail to find necessary condi- 
tions for development, and perish. 





Fig. 63.— Sarcinae. 



Fig. 64.— Yeast plant. 







Fig. 65.— Bacillus pneumoniae (Fried- 
lander) with gelatinous envelope. 



Pathogenic micro-organisms vary in length from one to forty 
(1-40 pt) micromillimetres, and in breadth from 0.5 to 7 yu. 1 Many 
micrococci are too minute to admit of accurate measurement. The 
largest micro-organism is the spirillum, which may reach a length of 



1 An jn (mikron) 



BACTERIA. 59 

0.2 of a millimetre. Perhaps a better idea of size can be conveyed 
by comparison with a similar object. The bacillus tuberculosis, 
which occupies in respect to size a median place, varies in length 
from -j-gVir *° 3^00 °f an inch, the smaller measurement being the 
average diameter of a corpuscle of human blood. Many species are 
endowed with motion, gyration, sometimes with address and agility, 
rotation and oscillation, flexion, extension, and locomotion. The ba- 
cilli of tuberculosis and milzbrand, together with all micrococci, 
have no motion at any time. That tremulous, molecular motion — 
the so-called Brown's motion — in the same place, observed also in 
inorganic matter, is to be distinguished, of course, from individual 
motion. Motion is often secured to micro-organisms by means of 
vibratile cilia, though most bacteriologists believe it to be a property 
innate or inherent to the protoplasm. 

Bacteria multiply by division 
(fission) — that is, by increase in size 
and separation into two (the cholera 
vibrio splits in two in fifteen to 
forty minutes) — or by the formation 
of spores, spherical bodies which 
elongate to form bacteria. Micro- 
cocci multiply only by division, and 
spores have not yet been distinctly 
demonstrated in spirilla. Bacilli 
form spores in two ways : by devel- 
opment in their interior, with sub- 
sequent liberation on rupture of the 

n .-,-, j iii Fig. 66. — Bacilli tuberculosis, showing 

bacillus — endospores ; or by devel- 
opment at an extremity, which falls 
away to constitute a new individual — arthrospores (apdpov, a joint). 
Endospores are much more tenacious of life than the bacillus, or than 
the arthrospore, which is endowed with no particular resistance. 
Hence endospores constitute what are known as permanent forms. 
In either case the protoplasm of the bacillus clears up at the point of 
formation of the spore, to assume the shape of a minute drop of 
greater diameter, at times, than the bacterium itself. Bacilli filled 
with spores, which may exist to the number of three or four, show a 
checkered or beaded surface. The activity of formation of spores is 
an index to the degree of nutrition. The liberated spore soon breaks 
the spherical surface with a point, which gradually elongates to 
form, in turn, the perfect bacillus. Spores may be recognized by 
their glistening, highly refracting contour. 

According to the mode of nutrition bacteria are divided into sap- 
rophytes ((ja7tp6^ } rotten), which live on dead soils, and parasites 







60 BACTERIA. 

(napaairos, feeding with or on), which live on living matter. Pa- 
rasites are also divided into obligates — that is, pure parasites — and 
facultatives, which may live both as parasites and saprophytes. 

Bacteria are again divided, according as they may live with or 
without oxygen, into aerobes and anaerobes. Here, too, there are ob- 
ligate aerobes, which can live only in the presence of oxygen, and 
obligate anaerobes, which can live only in the absence of oxygen. 
And here, too, there are facultative anaerobes, which may live in 
the presence of oxygen. 

Saprophytes thrive best at a temperature of 20° to 25° C, para- 
sites best at 35° to 40° C. Every micro-organism has its own pe- 
culiarities regarding temperature. Sunlight destroys all micro-or- 
ganisms ; even the most tenacious spores or permanent forms perish 
under the direct rays of the sun in the course of a few days. 

Bacteria are invisible not only because of their size, but also be- 
cause of their lack of color, and are rendered visible by various stains 
or dyes. For this purpose the best materials are the acid and basic 
aniline dyes, especially methylene blue and violet, gentian violet, 
Bismarck brown, f uchsin, and, of the acid anilines, eosin and acid 
fuchsin. They are usually prepared as follows : 

Alkaline methylene blue solution (Loffler) : Concentrated alco- 
holic methylene blue solution, thirty cubic centimetres ; liquor po- 
tassa? (1 : 10), one hundred cubic centimetres. 

Aqueous aniline dyes (Ehrlich) : Aniline oil, four cubic centimetres, 
thoroughly agitated with water, one hundred cubic centimetres, fil- 
tered after deposit ; whereupon is added concentrated alcoholic solu- 
tion of fuchsin or methylene violet up to distinct opalescence. 

Carbolic-acid-fuchsin (Ziehl-Neelsen) : Distilled water, one hun- 
dred ; crystallized carbolic acid, five ; alcohol, ten ; fuchsin, one. 

Iodine-potassium-iodide solution : Iodine, one gramme ; potassi- 
um iodide, two grammes ; distilled water, three hundred grammes. 
For use the solution is diluted to a Madeira color. 

The most generally employed is the carbol-fuchsin solution. The 
various micrococci, staphylococci, streptococci, FrankeVs diplococci, 
cholera vibrios, recurrent fever spirilla, and nearly all the pathogenic 
micro-organisms of man, as well as most of the saprophytic bacteria, 
are quickly and distinctly stained in this way. A large drop of this 
solution, let fall upon the object glass from a pipette and heated a few 
seconds to half a minute, suffices to color all bacteria distinctly. A 
few forms with dense membranes must be heated a whole minute. 

Bacteria are prepared for color, if in water or bouillon free of fat, 
by simply washing in water ; but, if in an albuminose fluid (blood, 
pus, or oedematous fluid of pneumonia) the cover glass should be 
dipped in absolute alcohol ; if in fat (milk or oedema of connective 



BACTERIA. 61 

tissue), the cover glass, after drying and before heating, should be 
placed a short time in absolute alcohol and ether. In. this way are 
colored not only the bacteria but also all protoplasm in the field. 

A valuable solution, especially in differential diagnosis, is that of 
Gram, which is prepared as follows : To ten parts of aniline water 
(i.e., the milky fluid which results from the agitation of four parts 
of aniline oil with one hundred parts distilled water) is added one 
part concentrated alcoholic gentian violet solution. The mixture is 
then passed through a filter moistened with water. The object glass, 
after drying and heating, is floated upon this stain five to fifteen 
minutes, sometimes under heat, and is then, without washing, ex- 
posed at least five minutes to the iodine-potassium-iodide solution. 
The blue-black color thus imparted is decolorized in first weak, then 
stronger, but not absolute, alcohol to a pale gray or yellow. Here- 
upon the specimen is dried in the air and examined under the oil of 
cedar or conserved in balsam. By the method of Gram all cell ele- 
ments are decolorized, while the bacteria maintain their dark-blue 
stain. Thus are colored the pneumococcus of Frankel, the strepto- 
coccus of erysipelas and acute suppuration, the staphylococcus of 
pus, the bacilli of anthrax, the mycelia of actinomyces, and the bacilli 
of tuberculosis. But the method of Gram will not color Friedlander's 
pneumonia bacillus, the typhus bacillus, the gonococcus, or the chol- 
era vibrio. 

As they are but indistinctly colored in this way, tubercle bacilli 
require special treatment. A particle of sputum compressed between 
two coloring glasses is spread out by the separation of the glasses. 
The specimen is then dried by the passage of the glass, held with 
forceps, about as fast as cutting bread, three times through a flame, 
specimen side up. The cover glasses are then dropped upon the ani- 
line water solution with f uchsin or gentian violet, or heated in this 
solution until vapor arises, then decolorized in a solution of nitric 
acid (1:4) and alcohol (sixty per cent). An aqueous solution of methy- 
lene blue or Bismarck brown furnishes the after-stain ; or, by a 
shorter method, the cover glasses or sections are colored in carbol- 
fuchsin, and then brought for one minute into a solution of water 
fifty, alcohol thirty, nitric acid twenty. 

Spores may not be colored after these methods, as their firm en- 
velopes prevent penetration. This resistance is overcome by subjec- 
tion to heated steam for an hour, or by passage seven to ten times 
through a flame. 

Bacteria are isolated and are further and much more positively 
distinguished by cultivation in certain soils. The first experiments in 
cultivating bacteria were made in fluids, solutions of meat, beef tea, 
chicken soup, malt extracts, infusion of hay, etc. ; but fluids are open 



62 



BACTERIA. 



to the objection that they admit other germs to coalesce with, and 

<>, . ^ „.. „ render impure, the special variety to be studied. 

_ y r i ' ,." 5^ Pure cultivations became possible only with the 

use of the solid culture soil first employed by 

v {, Koch. Germs falling upon a solid surface remain 



5 § 



- : 






'■:W 



I 'I 

u 



S% ; 





Fia. 68.— Scale surface culture 
(serum) of tubercle bacillus. 



Fig. 69.— Nail stick 
culture (gelatin) of 
pneumococcus. 



fixed in the same place. The solid culture soil 
made practicable the absolute isolation of germs, 
without which accurate investigation is impos- 
sible. Koch made his first studies with the com- 
mon potato. The potato was the key to the whole 
subject of solid cultures. What the apple was to 
Newton the potato was to Koch. Subsequently gelatin was employed, 



- 



Fig. 67.— Bacillus Hava 
niensis (Sternberg). 



BACTERIA. 63 

then aqueous humor, then gelatinized meat preparations, peptonized 
gelatins, etc. , and, as a climax, gelatinized blood. Thus has been 
determined the peculiar soil in which the varieties of pathogenic bac- 
teria thrive best. Moreover, it is seen that the colonies in their 
growth assume different forms or shapes, or exercise different effects 
upon the soil. Different bacteria vary also in the degree in which 
they fluidify the semi-solid substance of their soil. 

Lastly, pathogenic bacteria are distinguished by their physiologi- 
cal effects. From any special successive generation of a special 
variety of bacteria, material may be selected for introduction into the 
body or blood of various animals. Bacteria, or their products in 
culture soils, are introduced into animals by ingestion with food or 
by means of the oesophageal sound; by inhalation or insufflation of 
atomized matter; by intraperitoneal, intraocular, or intravenous in- 
jection, as into the external jugular or (in rabbits) posterior auricular 
veins ; lastly, by subcutaneous injection with the disinfected syringe, 
or by subcutaneous insertion with the platinum needle, usually into 
slight wounds of the skin, under thorough asepsis. 

Pathogenic micro-organisms act in two ways: by intoxication and 
by infection. Intoxication is a poisoning by products of micro-or- 
ganisms produced outside of the body ; infection is poisoning by 
products produced by bacteria inside the body. These sources are 
•sometimes distinguished as ectogenic and endogenic — terms destined 
soon to substitute miasmatic and contagious as applied to infectious 
disease. Intoxication is caused by the saprophytes, which may pro- 
duce ferments in food, as in meat, fish, sausage, milk, and cheese. 
The ferments may be infective even after destruction of the micro- 
organisms which caused them ; so food, even though cooked, may 
produce disease. The causes of infection are the pathogenic micro- 
organisms which multiply inside the body and evolve chemical 
products. The fact that pathogenic micro-organisms are not ab- 
sorbed proves that they produce disease by some chemical change. 
Moreover, the character of the sjinptoms — sopor, stupor, coma, 
delirium — which supervene in cases of grave acute infection speaks in 
favor of this view and against the belief that bacteria act mechanically 
or by the mere abstraction of oxygen. The only hitherto known 
poisons which may, in minute quantities, induce such grave toxic 
signs are the poisons resulting from the action of the bacteria of 
decomposition upon organic matter. As these intense^ virulent 
poisons were first observed only in dead organic matter, they were 
called ptomaines (7tTGopia, the fallen, a corpse ; hence more properly 
ptomatines). As many ptomaines are perfectly innocent, the term 
has been better substituted by Toxines. The toxines are nitrogenous, 
basic compounds, like the vegetable alkaloids, of complex com- 



64 BACTERIA. 

position. Among the non-poisonous ptomaines there have been 
extracted, in all cases from decomposing dead bodies, neuridin, 
cadaverin, putrescin, and cholin. Poisonous — i.e., toxiues — are: 
peptotoxin, present in many peptones ; neurin, in decomposing 
meat ; muscarin, the poison of the fly fungus, found also in decom- 
posing fish. From pure cultures of pathogenic bacteria have been 
extracted a toxine from the typhoid bacillus— typhotoxine ; from 
cultures of the tetanus bacillus and the amputated extremity of a 
man dead of tetanus, tetanin and tetanotoxin. Besides the pto- 
maines or , toxin es there are to be found certain albuminoid bodies, 
^products of micro-organisms, with similar poisonous but very differ- 
ent chemical properties, which are known as toxalbumins. Such 
toxalbumins have been separated from cultures of the diphtheria, 
typhoid, and tetanus bacillus. 

Animals, including man, vary in susceptibility to the action of 
micro-organisms and toxines. Certain animals are more, certain 
animals are less, liable or susceptible to contract or be inoculated with 
a disease. These animals are said to be, one predisposed to, the 
other endowed with, immunity to these diseases. 

The disposition to a disease may be natural — i.e., inherent — or 
acquired. 

Natural immunity may be overcome in various ways. Starvation 
makes pigeons susceptible to anthrax. The injection of papayotin 
leads to the appearance of hitherto latent micro-organisms to such 
degree, according to Bibbert, that the heart's blood will be thick with 
them in two hours; that is, the introduction of a vegetable ferment so 
profoundly alters the condition of the blood as to make of a hitherto 
sterile a fertile soil. So, also, certain ptomaines will reduce all en- 
ergy to such an extent that bacteria hitherto innocuous become infec- 
tious. According to Rogers, the immunity of rabbits to rauschbrand 
is overcome by the introduction of the innocent Bacillus prodigiosus. 
Guinea-pigs immune to chicken cholera are rendered susceptible by 
the injection of hydracetin or pyrogallol, substances which dissolve 
red blood corpuscles; and the addition of phloridzin, which causes a 
toxic diabetes, discharges the immunity of white mice to glanders. 

Hunger makes pigeons, naturally immune, susceptible to milz- 
brand. Fatigue acts in the same way with other animals. Thus 
white rats made to walk a wheel continuously for seven days lose 
their immunity. Temperature plays a similar role. Frogs kept 
at a temperature below 28° C. will not contract the disease, but will 
inevitably succumb to it at higher grades. Hydraemia lessens the 
susceptibility of rabbits to the staphylococcus by eliminating toxines 
through the kidney. Here is a hint regarding the value of free 
libations of water in the treatment of typhoid fever and other infec- 



BACTERIA. 65 

tions of man. Staphylococci injected into the peritoneal sac are re- 
sorbed without damage, unless the peritoneal endothelium be injured 
or diseased. Lipari found that the intratracheal injection of the 
sputum of pneumonia did no damage unless the animals were ex- 
posed to cold, which probably acted by producing catarrhal swelling 
and paralyzing ciliary motion, to permit the retention of bacteria. 
The so-called " mixed infection" occurs in this connection. Tuber- 
culosis admits the organisms of sepsis, as does also diphtheria. The 
organisms of measles and pertussis prepare the soil for tuberculosis, 
etc. 

The problem of medicine in the prevention and cure of disease is 
the reverse of this process, to wit, to confer immunity in lieu of lia- 
bility. 

Artificial immunity is conferred in various ways : 1. By increas- 
ing cell energy to resist the invasion of disease. Phagocytosis is an 
exemplification of this process. Healthy cells incorporate, digest, 





Fig. 70.— Trichomonas intestinalis. Fig. 71.— Naked amoebae coli. Fig. 72. — Cercomonas 

intestinalis. 

and destroy micro-organisms ; feebler cells yield before them. 2. By 
previous attack of a disease, as in inoculation of variola. 3. By 
inoculation of a milder form of the disease with attenuated micro- 
organisms or matter, as in the case of vaccinia and hydrophobia. 
4. By inoculation of substances extracted from the blood (serum) of 
animals which enjoy natural immunity, or to which immunity has 
been conferred. These principles may be also extracted from the 
milk (Ehrlich). 5. By inoculation of matters extracted from culture 
soils in which specific micro-organisms have been developed. 

Substances extracted in this way from the blood, milk, or from 
culture soils are known as antitoxines. Such antitoxines have been 
already found in tuberculosis (tuberculin), pneumonia, diphtheria, 
glanders, hydrophobia, tetanus, and typhoid fever. Future specific 
therapy lies in the direction of the discovery and perfection of anti- 
toxines. 

Protozoa are the very lowest forms of animal life. They are mi- 
nute masses of protoplasm of various shape ; sometimes naked, gene- 
5 



66 



BACTERIA. 



rally invested with a membrane ; sometimes enclosing pigment mat- 
ter and vacuoles, and sometimes ciliated, flagellated, etc. How 
protozoa find entrance into the body of man is as yet unknown, but 
they are certainly encountered in the blood, in various juices, or- 

L 




Pig. 73.— Plasmodium malariae : a, 6, c, intracorpuscular bodies; g, crescent; h, flagella. 

gans, and tissues of the body, epithelium, and, in some cases, defi- 
nitely in connection with certain diseases. 

Protozoa are divided, according to their modes of motion, nutri- 
tion, etc. , into three groups — the rhizopods, sporozoa, and infusoria. 
Rhizopods are, for the most part, naked — i. e. , membraneless — masses 
of protoplasm, with digital or filiform protrusions (pseudopods) to 
surround and incorporate food or foreign bodies, as in the amoebae, 
which belong to this group. 

Infusoria possess permanent cilia, 
by which they secure motion and ingest 
food into an oval orifice. Both infu- 
soria and rhizopods live on solid or 
semi-solid food. Sporozoa are covered 
by a cuticle having neither pseudopodia 
nor cilia, and are nourished wholly by 
osmosis. Sporozoa multiply by hard- 
shelled spores produced in the interior 
of the body. 

Perhaps the best-studied example of 
disease produced by protozoa is mal- 
aria. Blood withdrawn from any part 
of the body, especially from the spleen, 
but most conveniently and safely from 
the end of the finger, shows in this disease such masses of protoplasm, 
sometimes granular, sometimes crescentic, very often irregular, as to 
enable the practitioner in a doubtful case to declare the existence of 
the disease and differentiate it from simulating maladies. As these 




Fig. 74.— Coccidia from the human 
liver: A X 330, B and C X 1,000 (Leuck- 
art). 



BACTERIA. 



67 



bodies are to be found in all cases of malaria, and not in any other 
disease, increasing during fever, disappearing after the administra- 
tion of quinine or other antiperiodic, and as the inoculation of 
blood containing them conveys the disease, they are regarded as the 
specific cause of malaria, notwithstanding the fact that they have 
not yet been cultivated outside of the body. Protozoa belonging to 
the group coccidia have been recognized by Nisser in the nodules 
of molluscum contagiosum, a disease of the skin. The failure to 




^-S^> 



Fig. 75.— Scirrhus of the breast 
and small (Foa). 



epithelium enclosing protozoa, black stellate bodies, large 



discover micro organisms of other nature, and the recognition of pro- 
tozoa in these affections, have awakened the suspicion that certain 
exanthemata, also dysentery, abscess of the liver, cancer, etc., may 
depend upon, or be associated with, this cause. 

Pfeiffer depicts sporules found in the interior of the vesicles of 
herpes zoster, which is now regarded as an infection, also similar 
structures in varicella and variola vera ; and Yan der Loof finds cell 
forms — plasmodia — in the vesicles of vaccinia. 



CHAPTER IV. 

INFECTIOUS DISEASES. 

Up to the" present time it is definitely known that micrococci pro- 
duce pyaemia, septicaemia, furunculosis, acne, erysipelas, gonorrhoea, 
trachoma, pneumonia ; bacilli cause anthrax, diphtheria including 
croup, typhoid fever, tetanus, tuberculosis, lepra, glanders, measles, 
and typhus fever ; spirilla produce cholera and relapsing fever ; 
sporozoa cause malaria. 

Regarding other infections the evidence is not so positive ; in some 
cases it is probable, in others as yet only presumptive. 

SEPTICAEMIA, PYAEMIA, SEPTICOPYEMIA. 

Septicaemia ((?rj7rr6? P poisonous); Pyaemia; Septico-pyaemia. — In- 
fection (intoxication) of the blood and body by ferments, toxines, 
products of the various pus-producing micro-organisms, characterized 
by chills, high fever, profuse sweats, joint affections, metastatic de- 
posits, haemorrhages, diarrhoea, and nervous symptoms. 

These affections, which were formerly considered separate, are 
now known to be due to the same cause and belong properly together. 
Predominance of general signs of blood poisoning — i.e., nervous 
signs, high fever, etc. — in the absence of metastatic deposits, consti- 
tutes septicaemia ; predominance of metastatic processes, haemor- 
rhage, abscesses, etc., constitutes pyaemia; conjunction of the two 
sets of signs constitutes septico-pyaemia. 

Numerous micro-organisms produce pus and act as causes of this 
condition. 1. One of the most frequent is the Staphylococcus pyo- 
genes aureus, which, cultivated on gelatin or agar, shows, after ex- 
posure to light, gold-yellow colonies. Smaller numbers localized pro - 
duce in the skin acne, furunculosis, and subcutaneous abscesses; in the 
interior of the body, suppurations of bones and joints, of the lungs, 
pleura, liver, heart (endocarditis), and kidneys. The staphylococcus 
abounds in the air of crowded rooms. 2. The Staphylococcus pyo- 
genes albus, which forms white colonies. 3. The Staphylococcus pyo- 
genes citreus, which forms lemon-yellow colonies. 4. The Micrococcus 
pyogenes tenuis, which forms perfectly clear colonies. 5. The Strep- 



SEPTICAEMIA, PYAEMIA, SEPTICOPYEMIA. 



69 



tococcus pyogenes, which grows in chains of four, ten, or more mem- 
bers. The streptococcus has a much greater tendency to spread and 
to give rise to extensive phlegmonous processes. 

The various micro-organisms or their products, sometimes both, 




Fig. 76.— Pus from an acute abscess: a, pus corpuscles; 6, diplococcus; c, streptococci; d, set 
of four, tetrads (Woodhead and Hare). 

are introduced through breaks of the surface, wounds (parturient or 
puerperal uterus, etc.), or upon the heels of other micro-organisms in 



a'"" 



Fig. 77.— Septic infection of pectoral muscle after a " post-mortem " wound of the hand : a, 
perimysium with streptococci; b, cross section of unaffected muscle fibre ; c, cross section of af- 
fected fibre ; d, fibre penetrated by streptococci. 



the course of specific disease, tuberculosis, variola, dysentery, to cause 
a mixed infection or constitute the terminal link in the chain of disease 
process. 



70 



SEPTICAEMIA, PYEMIA, SEPTICOPYEMIA. 



Sometimes the avenue of entrance may not be seen or discovered. 
Poisonous matter may be introduced from the lungs, intestine, or 
other recess, to give rise, in light cases, to the symptoms of a " bad 
cold," dyspepsia, or rheumatism, or in bad cases to a pleuritis, ulce- 
rative endocarditis, etc. A searching investigation will sometimes 
discover the source of such infection at the prostatic urethra, ileo- 
caecal valve, interior or adnexa of the uterus (salpingitis), etc. 
Certain cases defy detection. These cases of concealed Origin are 
very appropriately called cryptogenetic sepsis — a term much more 
conducive to inquiry than "idiopathic" or "spontaneous," which 
rest upon entirely false conceptions. 

Symptoms. — The disease, considered as a septico-pyaemia, is ush- 
ered in suddenly in the course of puerperium, after a traumatism, 

operation, or in the midst of appa- 
rent health, with a chill or series of 
chills, followed by high fever, head- 
ache, vertigo, perhaps vomiting, and 
usually with well-marked nervous de- 
pression. The patient soon complains 
of pain in the region of the joints, 
which" are sometimes swollen and ten- 
der. The spleen swells early. Some- 
times there is icterus in light form from 
duodenal catarrh, in rarer (hematoge- 
nic) form from dissolutio sanguinis. 
The fever is continuous, subject to 
remissions, usually with evening exa- 
periodicity, but with periods of great 
The surface is cold 



mmm 

:;iss? s: 



nun 

Him 

i win 

mi 



SKK SSSIHS?.. 

SSiS Si HHHP 
...... 



Ilfll 



Fig. 78.— Temperature in a fatal 
case of sepsis. 



cerbation, with no distinct 
elevation (106° F.) followed by profuse sweats. 
and clammy. The hectic and night sweats of tuberculosis are really 
septic. The pulse is enormously quickened, is soon irregular and 
reduced in force. The patient falls into a typhoid state, with low, 
muttering delirium. Metastatic affection shows itself — in the skin 
as scarlatiniform rashes, herpes, pustules, pemphigus, petechiae, or 
larger haemorrhage, abscesses ; in the eyes as haemorrhage of the 
retina, irido-choroiditis, panophthalmia ; in the heart in irregular 
action, bruits mostly mitral, friction sounds of pericarditis, dyspnoea ; 
in the kidneys as albuminuria, haematuria, casts ; in the brain as 
embolic deposits, abscess, and haemorrhage. 

Diagnosis. — The disease must be differentiated from : 1. Typhoid 
fever, which has in common with it fever, diarrhoea, spleen tumor, and 
petechiae. Typhoid fever begins more slowly, is attended with 
mental dulness from the start ; the fever is more typical. Herpes, 
joint affections, mitral lesions, retinal haemorrhage, do not belong to 



SEPTICEMIA, PYEMIA, SEPTICOPYEMIA. 71 

typhoid fever. 2. Miliary tuberculosis, in which may be often dis- 
covered a local depot of tuberculosis in the lungs, lymph glands, 
spine, hip, etc. Meningeal tuberculosis is usually preceded by evi- 
dence of local infection in the way of bronchial and intestinal catarrh. 
3. From rheumatism, which has in common sweats and affection of the 
joints, but which has not successive chills, metastatic abscesses, affec- 
tions of the skin, eye complication, etc. 4. Cerebro- spinal meningitis 
also occurs suddenly, but prefers winter, soldiers, children, and shows 
with no, or much less, or more irregular fever, hypersesthesia, opisthot- 
onos, constipation, etc. o. Malaria shows more distinct fever, with 
quotidian or tertian periodicity, and is jugulated by quinine, which has 
no real control over pyaemia. The discovery of the Plasmodium in 
the blood of malaria, as well as of the typhoid bacillus in the spleen 
of typhoid fever, has already cleared up doubtful cases. Ulcerative 
endocarditis is itself evidence of septico-pysemia. 

The prog nosis is always grave, though it varies according to the 
range of the disease. Light cases readily recover. High fever, pro- 
fuse sweats, severe nervous signs are always grave. Metastatic 
deposits are ominous, though not of necessity fatal. Recovery has 
occurred even after affection of the eye. In every severe case recov- 
ery is tedious and protracted. 

Treatment. — Prevention is easier than cure. Modern methods of 
asepsis shut out entrance of pus micro-organisms to large extent and 
thus at least prevent the epidemics of former times. Prophylaxis 
pays scrupulous regard to dressings, instruments, personnel, etc. 
Depots of infection are excised or laid open and washed out. Mem- 
bers may require amputation, the interior of the uterus curetting. 
Wounds are dressed with antiseptics — sublimate solutions one per 
cent, carbolic acid five per cent. Rutter recommends: 

^ Iodoform 1 part. 

Ether 2 parts. 

Alcohol .' 8 parts. 

M. 

as a disinfectant wash, to be applied thoroughly into every crevice 
and recess of a wound. The actual cautery, Paquelin's thermo- 
cautery, galvano-cautery, furnish at times the finest results. In 
cryptogenetic cases everything depends upon the discovery of and 
destruction of the cause. A slow sepsis of months' duration has 
been stopped at once by the deep urethral injection with the Ultzmann 
catheter of a strong solution of nitrate of silver, gr. xx.- § i. ; and 
dangerous signs have disappeared after extirpation of a diseased 
ovary, after a laparotomy, trephining a mastoid process, etc. 

Drugs can do but little. Quinine in round dose, gr. v. every two 
to four hours, may help a simple case. The antipyretics are not 



72 ERYSIPELAS. 

much indicated in the treatment of a long fever whose cause is un- 
discoverable or ineradicable. The body may be saturated with sub- 
limate, small doses frequently repeated, one thirty-second grain every 
hour or two, or with creosote thirty or forty drops a day, as in the 
treatment of tuberculosis. It may become necessary to give opium 
to relieve pain or secure sleep. The only real address to the cause of 
the disease is in the exhibition of alcohol in the form of whiskey or 
brandy in large and frequently repeated doses. It is difficult to get 
the toxic effect of alcohol in a case of septicaemia. Alcohol feeds the 
body, lowers the temperature, and, to what extent it may, neutralizes 
the ferments and toxines of septicaemia. When the patient can no 
longer take alcohol the outlook is bad. 

ERYSIPELAS. 

Erysipelas (spvoo, to draw ; synonym, i'Xxao, e'kxos, wound ; 
Latin, ulcus, ulcer; 7t£\a$, near; Latin, prope ab aliquo loco, i.e., 
to spread; also, ipvdponekaS, epvaos, epvOpolj Latin, ruber, red; 
neXXa, pellicle, skin, vide Stephanus, " Thesaurus linguae Graecae"; 
whence in the sixteenth century the German Rothlauf, Rose, Wund- 
rose). — A specific acute infection of the surface of the body, always 
of local origin, and implying always a present or previous break of 
the surface, caused by the Streptococcus erysipelatis, marked by in- 
tense inflammation (pain, heat, redness, and swelling), high fever, 
gastric and nervous distress, a tendency to spread, and a liability to 
mixed infection (suppuration, phlegmon, gangrene), short duration, 
and in uncomplicated cases a restitutio ad integrum. 

History. — Erysipelas received its name in the most remote an- 
tiquity, and was, in the earliest history of medicine, associated with 
wounds of the surface. Yet this association was not considered a 
necessity in ancient times. Hippocrates recognized an idiopathic as 
well as a traumatic erysipelas — a distinction which found advocates 
up to the most recent times. This so-called erysipelas verum, s. 
spontaneum, the medical, as distinguished from the erysipelas spu- 
rium, s. traumaticum, or surgical form, was in the humoral pathol- 
ogy an inflammation of the skin excited by the escape of ' ' peccant 
matter" in the blood. Although Hippocrates and his followers 
included under the term many processes, suppurative, phlegmonous, 
gangrenous, etc., which we now consider complications, he had? 
nevertheless, a clear idea of the character of the disease. " In many 
cases," he says ("Epidemics," book hi., 4), "erysipelas, from some 
obvious cause, such as an accident, and sometimes from a very 
small wound, broke out all over the body . . . great inflammation 
took place, and the inflammation quickly spread all over . . . but 



ERYSIPELAS. 73 

these tilings were more formidable in appearance than dangerous, for 
when the concoction turned to a suppuration most of them recovered." 
The first vague intimation of the true cause of erysipelas is due 
to the penetrating insight of Henle (1840), the real pioneer of para- 
sitism, who maintained that it was introduced by the invasion of the 
lowest forms of vegetable growth, which were invisible because they 
could not be distinguished from tissue cells ; but the first distinct 
clinical exposition of the mode of origin of the disease belongs to 
Trousseau (1848), who insisted that even the medical, so-called non- 
traumatic cases " have almost always a starting point, which, though 
it cannot, strictly speaking, be called a wound, is at least a lesion, a 
small lesion of the integument at some point on the face [or else- 
where] , such as the corner of the eye, the nose, the lips, behind the 



Fig. 79.— Erysipelas cocci in the cutis (Eichhorst). 

ear, or on the hairy scalp." Specific micro-organisms had been 
claimed as the cause of erysipelas by Nepveu (1870), Hueter, Billroth 
and Ehrlich, Klebs, Orth, Tillman's and Wolff (1880), for the most 
part in the blood, but were first definitely discovered in the skin by 
Koch (1881), who observed them as chain-forming cocci, streptococci, 
exclusively in the lymph vessels and adjoining lymph spaces, but 
never in the blood vessels. Fehleisen (1881), independently of Koch, 
made the same discovery, and by isolating, cultivating, and inocu- 
lating the micro-organism in man for therapeutic purposes, as well 
as in the lower animals, confirmed his conclusions and established 
for all time the nature of the disease. 

Etiology. — The erysipelas coccus develops in serpentine form, as 
a bead or chain coccus, whose individual members, though very 
small, vary somewhat in size. It thrives in all kinds of culture soils, 
gelatin, agar, blood serum, milk bouillon, as well as upon the surface 
■of the potato ; with and without oxygen equally well ; best at a tem- 




74 ERYSIPELAS. 

perature of 30° to 37° C, but also at room temperature if not too low. 
It differs in no visible way from the pus streptococcus (Streptococcus 
pyogenes). Whether or not it is the same organism remains as yet 
an open question. Should it prove to be so, the suppurative and 
phlegmonous processes so often observed in erysipelas would be ex- 
plained by invasion of structures — viz., the loose subcutaneous tissue 
— which offer less resistance than the skin. It is found in greatest 
abundance in the zone of tissue just beyond the region of deepest 
redness, still uncolored by the inflammatory process. The lymph 
vessels and spaces of the skin, and later of the subcutaneous connec- 
tive and fatty tissues, are crowded to occlusion and distention by 
quickly multiplying streptococci, which have disappeared already 
from the visible zone of inflammation, either by reason of the short 
life of the organism or of consumption (incorporation) by the tissue 
cells and phagocytes, and not on account of the high fever they ex- 
cite, as they continue to develop 
at 40 o C, but with difficulty at 
43° C, to perish in twenty-four 
hours at 48° C. (118° F.). They 
seem to perish rapidly in the 
blood, as they are not found in 

Fig. 80.-Streptococcus erysipelatis : colony in the blood vesse l s though the pOS- 
a lymph vessel, ear of rabbit, two days after in- . . , . 

ocuiation(Ziegier). sibihty of metastasis in this way 

is proven by exceptional cases of 
intra-uterine (fetal) infection. Lebemeff found them in a section of 
skin of a child dead of the disease ten minutes after birth. Though 
Eiselsberg and Emmerich collected them from the air of surgical 
wards and operating rooms, as disseminated from particles of des- 
quamated skin, there is reason to rank the erysipelas coccus with the 
class of saprophytes, as similar cocci are discovered in various decom- 
posing matters, so that the parasitism of man 4 s an accidental inva- 
sion. Hajek claims that the body of man is not a very favorable soil 
for the growth of the erysipelas coccus, inasmuch as it is carried only 
by the lymph vessels, whereas the coccus of pus (phlegmon) develops, 
independently of lymph vessels, in every direction. Brieger and Was- 
serman dialyzed from the urine of a patient affected with consecutive 
nephritis a toxalbumin fatal to mice and guinea pigs. With resolu- 
tion of the erysipelas and nephritis the urine ceased to be poisonous. 

Age, sex, season, soil, have no influence in the production of the 
disease, which owes its origin exclusively to a specific cause, and 
which, once established in a house or institution, may develop upon 
the surface of an}', even the most trivial, break of the surface — mere 
abrasions, leech bites, old granulations, slight fissures, etc. — in a sus- 
ceptible individual. Vaccination had to be suspended in Boston in 
1851 on account of the frequency of erysipelas infection — an accident 



ERYSIPELAS. 75 

put beyond the suspicion of a mere sequence in the experience of 
Doepp, who infected every one of nine children by the use of lymph 
from a child that showed erysipelas on the following day. 

The erysipelas streptococcus has no power of attacking or dissolv- 
ing sound skin, but may easily penetrate the delicate connective tis- 
sue which constitutes a new cicatrix. Konig found in nineteen of 
thirty-six cases of " spontaneous" erysipelas a slight in jury, which 
could not be recognized in the rest on account of the great swelling 
of the affected tissues ; and Volkmann declares that scarcely an ex- 
ception can be found where ' ' idiopathic " erysipelas does not start 
from a wound, as from a scratched pustule or some such break. 
Auto-infection with the finger nails is an interesting illustration of 
this point. A medical student, under the observation of the author, 
affected with erysipelas of the face, reinfected himself in the leg by- 
scratching, and quickly succumbed to the double infection. Here, 
too, it must not be forgotten that light lesions, visible points of pre- 
vious infection, may be healed to leave no trace in twenty- four hours. 

The disease spreads for the most part by direct contagion ( i. e. , 
from bed to bed in a hospital ward), and remains thus confined to 
closed apartments — hospitals, prisons, ships, etc. In St. Bartholo- 
mew's it spread by attacking the nearest patient with an open wound. 
In the Berlin Charite erysipelas was confined, on one occasion, to the 
various occupants of certain beds directly over a defective privy pipe,, 
the repair of which put a stop to the disease. Radeliffe discovered 
and removed a similar cause of erysipelas in Oxford, in 1874, in 
choked sewer pipes. A still more instructive case occurred in the 
Middlesex Hospital, where erysipelas was strictly confined to two 
beds, successive occupants being invariably attacked ; with the re- 
pair of a flaw in a privy pipe, finally discovered in the adjoining 
wall, the disease disappeared for a time, to return in the same way 
after the lapse of ten years. Mindful of former experience, the pipe 
was again examined and again found defective ; on mending it no 
new case occurred (Zuelzer). Goodfellow reports a successive attack 
of every patient in a ward of thirteen beds, the disease going regu- 
larly down one side and up the other. 

Erysipelas thus rarely assumes epidemic proportions and seldom 
spreads over an entire community. Yet the germ may be conveyed 
by third persons or things, as by clothing, bedding, instruments, 
utensiTs, and cases of apparently spontaneous origin find explanation 
in this way. Thus, in a light epidemic at Rostock, Konig observed 
that the disease was confined to patients operated on in the amphi- 
theatre, and the cause was finally located in some blood- saturated 
pillows, the substitution of which by clean pillows ended the cases. 
A rabbit inoculated with an aqueous infusion of these pillows was. 
affected with a diffuse dermatitis which lasted twelve days. 



76 ERYSIPELAS. 

Overcrowding in hospitals, as during the existence of other epi- 
demics or during war, furnishes the conditions which favor the 
spread of the disease. This was so often the case in our civil war 
*' that it was frequently deemed desirable to establish i erysipelas 
wards' for the isolation and better treatment of those affected" 
(Woodward). Yet in all cases the specific cause must be first intro- 
duced. Thus, Calmeil relates that the Paris hospitals were crowded 
with patients affected with erysipelas in 1828 ; Schonlein observed 
an extensive epidemic in the hospital at Zurich in 1836 ; Gintrac de- 
scribed a similar occurrence at Bordeaux in 1844, where every inci- 
sion, cauterization, vesication, or venesection served as the starting 
point for an attack ; Trousseau remarked upon the coincidence of 
puerperal- fever in the Paris Maternite in 1858 with grave erysipe- 
las in the surgical division. In this connection it may be mentioned 
that Doyen (Rheims) declares that he was not able to discover a 
streptococcus among the micro-organisms of the vagina, so that it 
must be always carried to the uterus by hands, instruments, etc. 
But while pyaemia and gangrene were very frequent, erysipelas was 
almost unknown during the Crimean war, and Volkmann did not 
see a single well-marked case in Tratenau and other hospitals in 1866, 
where about one thousand wounded were quartered. And while 
the disease was very infrequent in quickly established and necessa- 
rily badly kept lazarettos in France, it attacked fully two per cent of 
the wounded in the " well-situated" hospitals of Berlin. 

The period of incubation is very short — but one or two days as a 
rule ; exceptionally, according to Heiberg, the temperature rose in 
the Rostock epidemic in two hours after a surgical incision. One 
invasion is said to rather predispose to than prevent subsequent at- 
tacks, though most cases of so-called habitual erysipelas are mere 
erythemas, simple dermatitis, carbuncles, drug eruptions, etc. 

Symptoms. — Erysipelas is usually introduced by a chill or series 
of chills, with malaise, anorexia, nausea, sometimes vomiting, 
headache, sometimes delirium, scanty urine, hot, dry skin, and fever 
in varying degrees of intensity. The temperature rises rapidly to 
102° to 105° F., to fall in three to five days, or reascend later with 
each new extension of the disease. The general symptoms are due 
to the development of a chemical poison, toxine, since the strepto- 
coccus does not enter the blood. 

The eruption or local manifestation shows itself most commonly 
about the face (in twenty-eight of forty-two cases — Hey f elder), on 
account of its greater exposure. The region of the nose is the most 
frequent starting point ; nose twelve, ear six, eyelids five, scalp five, 
etc. And this predilection for the face is observed even though 



ERYSIPELAS. 17 

wounds of the extremities are twice as frequent (Billroth) — a fact 
which of itself demonstrates outside infection. 

The eruption appears as a rose-red flash, which rapidly spreads 
from the part affected like red ink over blotting paper. The skin is 
swollen, glazed, and (Edematous; pits hence on pressure, and burns 
as if scorched by fire. 

If the nose be the starting point, the disease spreads toward the 
lips, ear, forehead, scalp, nucha, but not downward over the chin. 
Commencing elsewhere, as at the back of the neck or scalp, it pur- 
sues a reverse course, but still respects the chin. From the breasts 
it extends toward the axilla and over the chest, but does not pass 
down over the xyphoid cartilage. The germ follows the rhombic 
meshwork of the skin (as indicated by the lines of tension or elonga- 
tion after a circular punch), along which the lymph vessels course, 
and meets with obstacles where these lines cross, 
as at the chin and ensiform cartilage, or where 
the skin is bound down to bone or subcutaneous 
tendons. Visible tongue-like or dendritic pro- 
longations may reveal its progress in this way 
up to adjoining lymph glands, which show in- 
vasion by tenderness and swelling ; or wall-like 
indurations may indicate its advance en masse, 
erysipelas marginatum. Vesicles, always 
visible with a lens, and blebs frequently form 
on the affected surface. Barring exceptional Fr&. si. — Temperature 
cases (erysipelas fixum), the disease does not ^*^ cial8rr - 
last longer than four days in one locality, though 

previously affected regions may be revisited as a result of reinfec- 
tion. More widely or rapidly advancing cases constitute erysipelas 
migrans, s. ambulans, s. serpens. Vaccinal erysipelas in a feeble 
child may thus spread over the whole body in less than a week. 

The deep discoloration, more especially the great swelling, cede- 
matous infiltration, of the parts affected, produce deformities quite 
characteristic of the disease. The eyelids are puffed to complete 
closure, the nares blocked, the ears bloated, the lips protuberant, the 
face seems a shapeless mass or repulsive mask like that shown in 
small-pox. Drops of sticky serum ooze out upon the glazed surface 
from ruptured blebs, to add to the picture of distress. Infiltration 
of the scalp gives it a doughy sensation to the touch, lifts it from 
the cranium, or interferes to such extent with the nutrition of the 
hair as to cause it to fall — defluvium capillitii — to be restored, how- 
ever, in all cases with the subsidence of the disease. The back of 
the neck may present the appearance and give the discomfort of a 
huge carbuncle. 




78 ERYSIPELAS. 

At this time, during* the height of the disease, there is always 
more or less delirium, muttering, insomnia, or more frequently 
somnolence and coma, more rarely mania, especially at night. The 
tongue is heavily coated, fuliginous ; the spleen is swollen; the bow- 
els constipated ; the urine scanty, and albuminous from fever ; and 
complications of various kinds, some of great gravity, are liable to 
ensue. But just at this time, as a rule about the fourth or fifth day 
of the disease, when the gravest apprehensions are being entertained, 
resolution sets in, occasionally with epistaxis or herpes, more rarely 
with suppuration, with fall of temperature, subsidence of swelling, 
frequently with desquamation of the skin, and in an incredibly short 
time there is restitutio ad integrum — i.e., to leave no trace of pre- 
vious affection. And so, "as if by magic, a hideous monster was 
metamorphosed into a comely damsel " (Watson). The disease lasts 
usually three to ten days. 

Erysipelas is not confined to the outside skin. It may originate 
in or subsequently invade also the various mucosas, to produce the 
same changes as in the skin. Gerhardt thinks it questionable that 
we should regard all internal affections occurring during the course 
of erysipelas as directly caused by the disease, though he admits the 
possibility of an intimate connection with pericarditis. Diseases of 
the mucosae by extension from the skin or from border lines would 
seem to admit of no other explanation. So also subsequent exten- 
sion from the mucosa? to the skin, with typical manifestations in the 
skin, furnish evidence satisfactory to diagnosis. Thus, to quote one 
case from a now crowded literature, Wells reports an erysipelas fau- 
cium, characterized by fever, thirst, headache, swollen glands in the 
neck, pharyngeal oedema and redness, with phlyctenulse, subsequent 
invasion of the nose, and in forty-eight hours of the face, with typi- 
cal signs, and final recovery. Pozzi speaks of erysipelas of the nose, 
ear ducts, external auditory canal, drum cavity, and Eustachian 
tube. Cordone remarks that hitherto pharyngeal erysipelas has been 
considered secondary because of the absence of proof of primary af- 
fection by bacterioscopic examination. This proof he claims to have 
furnished in four cases of what he calls "unconditional" erysipe- 
las. In all these cases fluid withdrawn from phlyctenulse in the 
throat by a sterilized syringe furnished, among other micro-organ- 
isms, Fehleisen's streptococcus, as demonstrated by subsequent culti- 
vation and inoculation experiments. The pharynx offers a favorable 
nidus for erysipelas, he says, because of the richness of its lymph 
plexus. Thus in the throat erysipelas may simulate diphtheria or 
scarlet fever, the deeply reddened surface becoming swollen, tense, 
and oedematous ; in the larynx it may assume the sudden gravity of 
oedema of the glottis. The vagina is less frequently involved, but 



ERYSIPELAS. 79 

the coincidence of erysipelas with puerperal fever, already noticed, 
shows involvement also of the uterine mucosa. 

Complications. — Abscess of the skin, gangrene, bronchitis, pneu- 
monia ; more rarely, oedema of the glottis ; more frequently, endo- 
carditis, pericarditis, meningitis ; icterus, dysentery ; more rarely, 
cnterorrhagia, ulcer of the duodenum, peritonitis; according to Hart- 
mann certain cases of " spontaneous peritonitis are caused by the 
•erysipelas coccus " ; nephritis ; Cerne claims to have found the strep- 
tococcus in the urine ; affections of the joints ; exceptionally paroti- 
tis, keratitis, amaurosis, panophthalmitis ; paralysis. 

Diagnosis. — Erysipelas is written upon the surface in its intense 
redness and stuelling, origin about a wound, characteristic deform- 
ity, fugacity, and restitutio ad integrum, together with the con- 
stitutional distress and complications. It is distinguished from 
erythema by the more tense, glazed, and cedematous condition of 
the skin, arising about a broken surface, by its more strict locali- 
zation, blebs, indurated margins, fever, with other signs of toxae- 
mia which do not belong to erythema. Erythema nodosum, though 
associated with fever and often with gastric distress, is recognized 
by its nodosities, especially about the joints. Drug eruptions after 
the antipyretics, copaiba, etc., have a history, less severe local, and 
no constitutional signs. Malignant pustule (milzbrand) and malig- 
nant oedema, rare affections, show characteristic bacilli ; erysipelas, 
characteristic micrococci. 

Prognosis. — The prognosis is favorable as a rule, for, as observed 
by Hippocrates, the disease is more ' ' formidable in appearance than 
reality." The occurrence of suppuration, which is comparatively 
rare, and is certainly indicative of mixed infection, does not aggra- 
vate it greatly. ' ' Verum ac legitimum erysipelas raro terminatur 
suppuratione, sed magna ex parte insensibili transpiratione seu reso- 
lutione" (Yidus). Previous debility reduces the rate of recovery, 
and symptoms on the part of the nervous system are especially 
threatening. Rapid spread, undue protraction, reinfection, relapses, 
complications, gravely affect the natural tendency to resolution. 

Prophylaxis is difficult on account of the extreme tenacity of the 
streptococcus, which fixes itself to walls, carpets, curtains, bedding, 
almost ineradicably. Ferraro propagated erysipelas from strepto- 
cocci kept dried on a silk thread fifty -two days. Walls should be 
rubbed down with bread; furniture disinfected by long ventilation in 
the open air ; rooms flushed with fresh air day and night ; floors 
scrubbed with corrosive sublimate ; bedding, clothing, etc. , subjected 
to steam heat or destroyed by fire ; patients isolated as much as 
may be. Attendants should not wear woollen clothes. Above all 
things, instruments, best wrapped in towels, should be placed in 



80 ERYSIPELAS. 

boiling water for five to ten minutes, and utensils thoroughly scalded 
out. 

Treatment. — The treatment of erysipelas is based upon attempts 
to destroy or limit the extension of the streptococcus, and to support 
the patient during the progress of the disease. Fehleisen found 
that thin layers of the streptococcus perished in a one-per-cent solu- 
tion of carbolic acid in forty-five seconds. Gartner and Plagge de- 
clare that cocci cultivated in bouillon feel the deleterious influence 
of a three-per-cent solution of carbolic acid in eight to eleven sec- 
onds. Hartmann observed all streptococci, wet or dry, perish under 
five to ten minutes' exposure to undiluted liquor ferri sesquichloridi, 
which absolutely destroys those on the surface, but only limits or 
checks the development of those deeper in the tissues. These facts 
furnished by the bacteriologist give the clue to the scientific treat- 
ment of the disease, as well as explain the failure of specific treat- 
ment hitherto. 

Mild cases require no treatment beyond wet compresses or inunc- 
tions to relieve the heat and tension of the surface. More severe or 
rapidly spreading invasions may be attacked by antimycotic agents, 
at the head of which stand the agents mentioned. External appli- 
cations are obviously useless. The fact that so many practitioners 
of the ' ' school of experience " possess specific applications, each dif- 
ferent from the rest, is patent proof of the inefficiency of all of them. 
Scientific disproof of such specificness is offered in the report of 
Polotebrow (1888), of St. Petersburg, who made parallel observa- 
tions in sixty cases, thirty of which were treated with cold-water 
compresses alone and thirty with energetic applications of nitrate of 
silver — 4 : 30 — over the affected surface and two or three fingers' 
breadth beyond it, without influence on the temperature, nervous 
symptoms, albuminuria, or other complications, and without appre- 
ciable difference in the duration or mortality, which was one in each 
set of cases. Hueter first employed carbolic acid subcutaneously, 
introducing the agent beyond the limit of invasion. This treat- 
ment, which is admirably adapted to the trunk or extremities, is 
impracticable about the face or scalp. Bogusch recommends the 
subcutaneous injection of resorcin 1.5:30 aqua destillata ; Cattani, 
the application of the same agent, two- or three-per-cent solution, 
every two hours, externally by means of a brush or saturated cot- 
ton, together with its internal administration (4:6) in water, barley 
water, or red wine. Hucker advises the painting of the surface 
with cocaine in relief of pain. Hofmokl applies compresses of a 
three- to five-per-cent solution of carbolic acid, and covers them 
with some material impervious to water. Lovanz paints the surface 
repeatedly with a mixture of ichthyol twenty, glycerin and ether 



ANTHRAX. 81 

each ten. Duckworth uses an ointment of equal parts of chalk and 
melted fat. Barwell applies white lead as quickly and as thickly as 
possible. The Berlin Charite paints the surface with a concentrated 
solution of carbonate of lead in glycerin, and covers it all in with 
cotton. Popoff applies with a brush trichlorphenol, five-per-cent 
solution, in glycerin. Winiwarter claims to check the spread of ery- 
sipelas migrans as follows : The affected surface is washed, or, if the 
extremities, bathed, in a three-per-cent solution of corrosive subli- 
mate. Next is applied to it, and to two fingers' breadth beyond it, a 
thick layer of tar, which is now covered in. The covered surface 
becomes macerated in a few days, and is next redressed with subli- 
mate water in but one-per-cent solution, which thus checks the fur- 
ther advance of the disease. Much more radical treatment is prac- 
tised by Kraske, who makes multiple punctate scarifications and 
small incisions one centimetre long through the corium, and in places 
through the whole skin, washes over and rubs into the surface a 
five-per-cent solution, and covers it all in with compresses saturated 
with a two-and-one-half-per-cent solution of carbolic acid. 
A recent remedy, highly lauded, is : 
R . Iodoformi, 

Creolini aa gr. xv, 

Unguenti petrolati 3 ss. 

Lanolini § iss. 

M. Apply with a brush. 

The use of this preparation is said to check fever and stop the 
spread of the disease after three applications. Wolfler claims to 
have cut short fifty-eight of sixty cases by strapping the surface 
with adhesive plaster. 

The real value of any or all of these remedies remains to be tested 
by time. They seem at present to show the direction of modern 
therapy as determined by etiological discovery. 

Few practitioners will now maintain a specific action for any in- 
ternal remedy, though none will deny the necessity of sustentation of 
the patient by alcohol, if necessary, until the disease shall have run 
its course. 

The natural tendency of the disease to resolution in the course of 
a few days makes it difficult to decide whether any ' ' cure " be due 
to Nature or to art. 

It is wise to keep the bowels open with calomel and Carlsbad 
salts, to allay nausea and vomiting with small doses of chloral, gr. 
ii.-v. in peppermint water. Here, as everywhere, "ubi pus, ibi 
incisio." 

ANTHRAX. 

Anthrax (avOpag, coal) ; carbuncle ; malignant pustule ; splenic 
6 



82 



ANTHRAX. 



fever; German, Milzbrand ; French, charbon. — An exquisitely 
acute, often fatal infection, caused by the Bacillus anthracis ; charac- 
terized by the formation of a boil with a black centre (anthrax), ex- 
tensive circumjacent infiltration, and subsequent sepsis ; in internal 
form by rapid toxaemia and the development of metastatic carbun- 
cles in the skin. 

History. — Anthrax existed in the most remote antiquity. It is 
recognized that most of the fatal plagues which chiefly affected ani- 
mals, and not infrequently men, correspond to the sjunptomatology 
of anthrax. The plague of murrain with boils and blains, on man 
^and beast, mentioned in Genesis, is believed to have been anthrax 
(Blanc). 

The Bacillus anthracis (Pollender, 1855) is famous as the first 

micro-organism discovered as the 
actual cause of an infectious dis- 
ease. It is the longest known and 
best studied of all the micro-organ- 
isms. 

Etiology. — The milzbrand ba- 
cillus is a motionless rod of elon- 
gated, jointed cells, 0.005 to 0.0125 
mm. in length — i.e., two to ten 
times as long as a red blood cor- 
puscle— 0.001 to 0.0015 mm. broad. 
Under proper conditions it forms in 
the culture soil, but never inside of 
the body or tissues of the living ani- 
mal, endogenous spores. Decom- 
position, the action of the gastric 
juice, quickly destroy the bacilli, but fail to attack the spores. The 
ingestion of meat free of spores produces no infection. The inges- 
tion of meat with spores infects infallibly. In San Domingo (1770) 
fifteen thousand persons perished in six weeks from eating the bodies 
of animals dead of the disease. Freezing affects neither the bacilli 
nor the spores. 

Anthrax infects chiefly herbivora, next omnivora, least carnivora, 
man as an omnivorous animal. The disease is therefore not quite so 
dangerous in man as in some other animals. The Bacillus anthracis 
is a saprophyte. It goes through with all its phases of development 
outside, and makes only accidental incursion into, the body of man. 
Martin succeeded in extracting from cultures certain chemical pro- 
ducts : first, proto- and deutero-albumose ; second, an alkaloid ; 
third, small quantities of leucin and tyrosin. Mice injected with the 
proto- and deutero-albumose were affected with oedema at the place 




Fig. 82.— Anthrax bacillus, with and without 
spores, from spleen (Woodhead and Hare). 



ANTHRAX. 83 

of injection, and with a sufficient quantity (0.3 gramme for a mouse 
weighing 22 grammes) they were killed. Similar symptoms were 
produced with the alkaloid (0. 1 gramme fatal to a mouse weigh- 
ing 15 grammes). Hankin also found an albumose which he in- 
jected in prophylaxis against the disease. Anthrax is peculiarly 
malignant in small animals. It is so surely and quickly fatal to 
mice, guinea-pigs, and rabbits as to make their bodies the best phy- 
siological tests in cases of doubt as to the nature of a micro-organ- 
ism. 

Anthrax is usually conveyed to man by contact with a diseased 
animal or by the ingestion of its flesh as food. Individuals most 
closely connected with cattle are chiefly affected — butchers, stable 
boys, shepherds, veterinary physicians, etc. On account of the great 
tenacity of the spores, people who come in contact at any time with the 
skins, hairs, bristles, cloths, horns, hoofs — as tanners, brushmakers, 
upholsterers (horse-hair), wool sorters, rag sorters, glue makers, etc. 
— may be affected through open wounds in the skin or through in- 
halation of dust. 

Since Bollinger demonstrated the bacillus in the stomach of car- 
nivorous flies, and with Raimbert and Davaine produced the disease 
by inoculation with the stomach, legs, and feelers of these insects, it 
must be admitted that malignant pustule may be conveyed by in- 
sects. It had long been remarked that malignant pustule occurs 
more especially on the exposed parts of the bod} T — face, hands. 
Bell, of Brooklyn, found fifty-six of sixty cases on the face, two on 
the hands, one on the wrist, and one on the forearm. It was evident 
that the bite of a fly or mosquito had often originated the disease. 
Extensive epidemics have been caused, as stated, by the ingestion of 
raw or insufficiently cooked flesh. Animals rarely contract the dis- 
ease from each other ; they get it from the soil. It has often been 
observed that certain regions are centres of infection where the dis- 
ease shows itself year after year. The superficial burial of carcases 
leads to infection of the soil, which, once produced, is seldom eradi- 
cated. The disease is spread chiefly in the warm months of summer, 
when the soil is softer, by grazing upon its surface, and is trans- 
ported by streams of water which convey infected soil to a distance. 
Floods may disseminate the disease to places previously free. Stable 
utensils, fodder, hay from anthrax fields, litter, harness, surgical 
instruments, have been known to convey the disease. The foetus is 
not infected as a rule. The placenta, when sound, acts as a filter. 
Exceptional cases have been accounted for by lesion of the placenta. 
Immunity is not secured by a single attack.. 

Symjjtoms. — The disease presents itself in two distinct forms, 
one as it originates externally, the other internally. The external 



84 ANTHRAX. 

disease is the anthrax, malignant pustule, or charbon, with its le- 
sions in the skin and subjacent tissues. The internal is the intestinal 
or thoracic mycosis, which is recognized by the general signs of 
toxaemia, the nature of which may be, if unsuspected, overlooked. 
The external disease is confined to individuals ; the internal may as- 
sume, as stated, endemic and epidemic proportions. 

The period of incubation varies from one to several days. Symp- 
toms may show themselves in a few hours after inoculation. They 
may be delayed as late as four days. A slight itching, prickling. 
or burning sensation is first perceived on the face or neck at the 
site of inoculation. Sometimes the patient feels as if he had been 
just stung by an insect. Very soon appears a papule with a central 
vesicle, the rupture of which discharges bloody contents, to be con- 
verted into a dark red-brown or black crust — the anthrax. Smaller 
vesicles may appear about it. The parent nucleus, as Virchow 
called the first eruption, rapidly extends ; the skin swells about it, be- 
comes indurated, livid, and hard. The subcutaneous tissues are ex- 
tensively infiltrated with serum. The appearance is characterized 
as a " brawny oedema," which rapidly spreads to involve a mass of 
tissue, the whole of one arm or of one side of the neck, in the course 
of a few days. Lymphangitis and swelling of the lymph glands, 
with. phlebitis, are frequent complications. For the first day or two. 
there may be no disturbance of the general health, the patient may 
even continue at work ; but toxic signs set in, as a rule, by the end of 
the second day, with delirium, diarrhoea, sweating, vomiting, and 
collapse, and so the patient may die of heart failure in five to eight 
days. This result, however, is not so frequent as was formerly sup- 
posed. In the majority of cases the local inflammation begins to 
abate in the course of a few days. The anthrax sloughs off and the 
subjacent ulcer closes over by granulation. 

A sub-variety of this condition was first described by Bollinger 
as anthrax oedema. In this form the local lesion is absent. The 
poison seems to be introduced more deeply into the tissues,, and 
chemical products produce an cedematous state of wide range. This 
variety is most often noticed in the region of the eyelids. 

The internal mycosis announces itself more distinctly as an infec- 
tion. The disease begins suddenly with chill, pain in the head and 
joints, vomiting, and diarrhoea. The case looks like a poisoning, 
which it is. Free haemorrhage may occur from the mouth, nose, 
and kidneys. Nearly always (exceptions by Bonisson) there is an 
outbreak upon the skin of small, phlegmonous, carbuncular inflam- 
mations, the so-called metastatic carbuncles. There is usually but 
little fever. There may be much delirium, convulsions? sometimes 
opisthotonos. There is often prozcordial anxiety and intense 



ANTHRAX. 85 

dyspnoea. Cyanosis and heart failure usually precede the termina- 
tion, which may occur in the course of a very few days. 

Where the disease originates in the chest respiration soon be- 
comes difficult, though auscultation reveals, as a rule, only the signs 
of a light bronchitis. Diarrhoea is usually absent. The nervous 
system may be depressed, or so little affected as to lead patients to 
decline medical advice, even a few hours before death. The case 
bears the aspect of a rapidly spreading pneumonia with heart fail- 
ure. Most of these cases succumb in three to five days. Bell de- 
clares that they who survive for a week recover. This form of the 
disease has been observed more especially among the sorters of wool. 
Most of the fatal cases have been hitherto unrecognized. Bell 
thinks that many of the cases diagnosticated as pneumonia, bron- 
chitis, congestion of the lungs, etc., occurring in factories of carpets, 
blankets, furs, etc., are really cases of thoracic anthrax. It is not 
improbable that some of the cases ascribed to poisoning by mush- 
rooms, meat ptomaines, etc., are really cases of intestinal anthrax. 

Diagnosis. — Anthrax is distinguished by its 
origin as a red papule with a dark centre — 
"gran nero" — and its rapid extension with 
brawny oedema. The black central crust is ab- 
sent, and any extensive surrounding inflamma- 
tion is absent, in a common boil or furuncle. 
There is a furunculosis of the upper lip which is ^ l^*lP 

more fatal than anthrax (Konig). Carbuncles FlG - 83 -- The anthrax 

, . , , in ,i ,, bacillus in the blood. 

show themselves much more trequently on the 
back of the neck, trunk, and extremities ; anthrax occurs on uncov- 
ered surfaces. Anthrax spreads from one central point or parent 
nucleus ; carbuncle results from the coalescence of a number of 
points. Anthrax oedema, in the absence of a central papule, is dis- 
tinguished by its sudden appearance, its yellow-greenish hue, and 
septic symptoms. Erysipelas is more superficial, has no anthrax or 
parent nucleus, and shows no bacteria in the blood. 

The diagnosis of intestinal and thoracic anthrax is sometimes 
reached only by exclusion. The nature of the avocation, the exposure 
to the cause, is the most common index to the condition. The sud- 
den occurrence, in the midst of health, of the intense signs of a grave 
infection — headache, nausea and vomiting, dyspnoea, cyanosis, con- 
vulsions, free haemorrhages, especially of skin carbuncles —in connec- 
tion with the history of exposure, should lead to the recognition of 
the disease. In any case of doubt the diagnosis may be established 
by the examination of the blood under the microscope, or by a phy- 
siological test. A rabbit, guinea-pig. or a mouse shows dyspnoea, 
dilatation of the pupils, and convulsions, with death in the course of 




86 ANTHRAX. 

two or three days after inoculation. The blood of these animals 
then swarms with bacilli. 

The prognosis is always grave ; that of malignant pustule de- 
pends upon the stage of its recognition. The disease can be always 
eradicated at first. In places where its picture is familiar, and 
where the disease is attacked at once, the mortality is reduced to 
five to nine per cent, and even this mortality is ascribed to delay in 
treatment. Under neglect the mortality may reach fifty to sixty per 
cent. Intestinal and thoracic anthrax, recognized only after general 
infection, have always, at least at present, a fatal prognosis. 

Prophylaxis consists in the proper disposition of the bodies of 
dead animals by deeper burial or by cremation ; by the avoidance 
of the use of the hides or other products of these animals ; by the 
destruction of their discharges, as by fire ; by shutting off affected 
pasture fields, damming up streams of water, etc. ; by the abundant 
use of disinfectants — carbolic acid, chloride of lime, corrosive sub- 
limate — in handling suspected wools, horns, and other products ; and 
by protective inoculation of cattle and sheep with attenuated cultures 
or antitoxines — a procedure the value of which is yet sub judice. 

Treatment. — The successful treatment of anthrax depends upon 
the energy of the local attack. Deep crucial incisions should be 
made through the substance of the mass, and the gaping cuts stuffed 
with carbolic acid fluidified by heat. They should be afterward 
dressed with the more dilute solution 1 : 10. Individual carbuncles 
may be excised en masse or excavated with a sharp spoon, where- 
upon the base must be treated with powerful caustics — carbolic acid 
as stated, corrosive sublimate, caustic potash, etc. Camera best 
expresses the principle of treatment with the most successful practice 
in countries where the condition is most frequently encountered, as 
•follows : The mass is to be circumscribed by a deep incision and 
penetrated by numerous crucial incisions. Into the bottom of all 
these cuts is to be strewn corrosive sublimate itself, in powder, 0.04 
to 0.15. The liquefaction of the sublimate produces extensive, thor- 
oughly penetrating destruction of the entire mass. Where the sur- 
face is so great as to lead to the fear of poisoning by the sublimate 
itself, its action may be modified and poisoning prevented by ad- 
mixture with a proportion of calomel. Weil first anaesthetizes the 
mass with cocaine, scoops it out, and applies to the wound dressings 
saturated with a one-per-cent solution of corrosive sublimate. Con- 
tento injects into, under, and about the mass subcutaneously three- 
per-cent solutions of carbolic acid. In the (Edematous form the 
whole infiltrate must be abundantly scarified and cut deep down 
to the healthy tissue in the same way, and dressed in solutions of 
iodine and carbolic acid. 



FOOT AND MOUTH DISEASE. 87 

In the cases of general infection metastatic carbuncles are to be 
treated in the same way, and the patient supported with brandy or 
subcutaneous injections of ether, camphor, or other analeptic. 

The therapy of internal anthrax is well-nigh hopeless. Where it 
is known that poisoned meat has been ingested, the stomach should 
be immediately washed out, or a powerful emetic administered, fol- 
lowed by a purgative dose of castor oil. For an internal mycosis it 
has been recommended to administer carbolic acid in dose of three 
to five drops three or four times a day. It might be better to 
saturate the blood with creosote, as in the treatment of the sepsis of 
tuberculosis ; and with alcohol, as in poisoning by snake bites. Not 
much hope is to be entertained from either plan. The hope which 
seemed justified by the experiments of Fodor regarding protection 
by saturation of the blood with an alkali, has proven futile accord- 
ing to the subsequent investigations of Chor. Future success must 
be obtained by means of sozines or antitoxines. Hankin, of Cam- 
bridge, finds certain defensive proteids in the serum of the blood of 
certain animals. There is a protective albuminoid, a non-dialyzable 
globulin insoluble in alcohol and water, in the blood and spleen of 
a rat, which renders a mouse immune against the most virulent 
anthrax. Kostjurin and Krainsky reached the conclusion that cer- 
tain toxines from decomposition, introduced at the proper time into 
the bodies of rabbits affected with anthrax, totally prevent the de- 
velopment of the disease. Ogata and Jasuhara claim that the blood 
of animals, dogs, fowl contains a ferment which, injected subcu- 
taneously in but one- or two-drop doses, acts as a preventive and 
curative remedy. These disclosures of much promise have not yet 
been utilized in the treatment of anthrax in man. 

FOOT AND MOUTH DISEASE 

Latin, aphthce {anroo, to fasten) epizooticce ; German, Maul 
klauenseuche ; French, stomatite aphtheuse; Italian, febb re af. 
tosa. — A mild, acute infection of the lower animals, especially of 
cattle, sheep, pigs, less frequently of the goat and horse, much more 
rarely of fowl, dogs, cats, evidently caused by a peculiar micro- 
organism not yet exactly defined ; characterized by the formation of 
vesicles and ulcers in the mucous membrane of the mouth, with the 
development of eruptions and ulcers in crevices about the feet, some- 
times about the udder ; communicable to man for the most part 
through the milk of diseased animals, to appear, with malaise and 
light fever, as vesicles and ulcers in the mouth, of benign course and 
short duration. 

History. — The disease was recognized in animals in antiquity, 
but was, in the early history of veterinary medicine, evidently con- 



88 FOOT AND MOUTH DISEASE. 

founded with anthrax and actinomycosis. Hertwig (1834) established 
the contagiousness of the disease by experimenting upon himself and 
two other medical men. They drank daily for four days a quart of 
fresh milk from diseased cows. Symptoms of fever, headache, dry- 
ness and heat in the mouth, and itching in the hands and fingers 
began in two and lasted for five days, at the end of which time 
vesicles appeared in the mouth. The disease has now, therefore, a 
recognized place in human pathology. Though benign in its mani- 
festation and course, it is nevertheless a serious affection from the 
fact that so many young animals, sucklings, succumb on account 
of degradation of the milk. It is stated that in many epizootics 
^as many as seventy-five per cent of sucking calves perished. The 
disease, once developed, is exceedingly persistent. Stables remain 
infectious for a long time. It is gradually transported along the 
lines of travel, hence along the course of rivers, and with a general 
tendency westward, to assume at times very wide range. Thus in 
the year 1871 seven hundred thousand animals were attacked in 
England alone, entailing in the same year in France a loss of thirty 
million francs. In 1869 the disease ranged over nearly all Eu- 
rope. It makes up for its mildness by its range, and costs a country 
more than the malignant diseases, anthrax, glanders, and rinder- 
pest. 

Etiology. — The infectious principle, evidently a micro-organism, 
has not yet been distinctly isolated. It is certainly distinctly com- 
municable by inoculation. Nesswitzky (1891) conveyed it with the 
contents of vesicles and secretions of ulcers, as well as with milk. 
Inoculation failed in the experiments of the Berlin Health Office in 
30. 3 per cent of cases. Klein, Siegel, and Schottelius isolated micro- 
organisms, but with no other proof of pathogenesis. 

The disease shows itself in the lower animals as a mild fever 
attended with a catarrhal inflammation of the mucosa of the mouth 
and the formation of vesicles and pustules about the feet. The milk 
of the affected animal is altered in quantity and quality. It is 
reduced often as much as one-half in man, assumes a yellowish 
colostrum-like appearance, and coagulates prematurely. It has 
a bitter, nauseating taste and deposits a dark-yellow sediment. 
The disease terminates usually in twelve to fourteen days. 

Man is usually affected through diseased milk, which retains its 
infection even when added to coffee or when diluted with normal 
milk in the proportion of one to ten. Boiling absolutely destroys the 
poison in the milk and renders it perfectly harmless. It is doubtful 
if the disease may be conveyed by the meat of diseased animals, but 
instances of infection have been reported from the ingestion of butter 
and cheese made from the milk of diseased cows. Infection by 



FOOT AND MOUTH DISEASE. 89 

direct inoculation, as in milking, is not uncommon in those who have 
the care of diseased animals. 

The chief interest in connection with foot and mouth disease 
occurs in relation to aphtha, which is declared to be the expression 
of the disease in man. It has been observed that aphtha prevails in 
children coincidently with outbreaks of the foot and mouth disease in 
cattle. What lends also especial support to this view is the fact that 
the appearance of the disease is much the same in man as in the 
animals. 

Symptoms. — The period of incubation in man ranges from three 
to five days. The disease may begin with ch ills, or chilly sensations, 
followed by fever, anorexia, and malaise. Vesicles now appear 
upon the inner surface of the lips and tongue. Along with the 
sense of heat and dryness there is difficulty in speaking, chew- 
ing, and sic all owing. The mucous membrane is very much red- 
dened and swollen, and saliva floivs abundantly. There is often 
noticed also at this time a vesicular eruption on the ringers and 
hands, sometimes in association with intestinal disturbance. The 
vesicles upon the fingers axe at first small and transparent. They 
soon increase in size and change in color to show purulent contents, 
and sometimes closely simulate the eruptions of small-pox. Cases 
have been reported where the eruption was so extensive as to cover 
the entire body (Biercher). Holm saw vesicles on the nipple of the 
breast in a woman who drank daily large quantities of milk from 
cows affected with the disease. 

The catarrhal inflammation may assume such proportions as to 
constitute an extensive stomatitis. Briscoe saw a case in which the 
tongue was so much swollen as to project more than an inch from 
the mouth. 

Projjhylaxis includes proper care of the animal regarding pas- 
turage and stables. Man is best protected by the ingestion of milk 
from healthy cows. or. if that be impossible, by the thorough boiling 
of milk from diseased cows. 

The diagnosis is usually easy. It may be known that the disease 
exists at the time in animals. The peculiar coincidence of eruption 
in the mouth and extremities, sparing the rest of the body, is unlike 
any other eruptive disease. Thus the mycoses of the mouth are un- 
attended with affections of the feet, and eczemata, etc., of the feet are 
unassociated with eruptions of the mouth. 

The prognosis is favorable. The disease runs a mild course, and 
terminates, as a rule, in from five to eight days. Extensive affection 
of the hands, with the difficulty of proper protection, may extend the 
disease to several weeks. Fatal cases have been reported in very 
delicate children. 



00 GLANDERS. 

Therapy. — Stomatitis is best treated with weak solutions of borax 
as mouth washes. Erosions and ulcers should be cauterized with the 
nitrate of silver, which not only protects an abraded surface from 
irritating contact, but also by its antimycotic properties directly ad- 
divsses the cause of the disease. The superficial lesions of the ex- 
tremities may be best treated by lead washes, diachylon ointment,. 
light bandages, etc. The fever and general distress of infection may 
call for mild or repeated doses of salicylates, phenacetin, chloral, 
or Dover's powder. 

GLANDERS. 

Glanders (from gland) ; farcy (from farcio, to stuff); Greek, jaoc- 
Xi? ; Latin, malleus, maliasmus ; German, Rotz, Wurm ; French, 
morve, — An infection, acute or chronic, of the horse and allied soli- 
peds, ass and bastards, communicable by inoculation to many domes- 
ticated animals (but not to cattle) and to man ; produced by the 
Bacillus mallei; characterized by the formation of nodules (granulo- 
mata) and ulcers in the mucous membrane of the nose, with dis- 
charge of fetid pus, as from glands (whence glanders), and also by 
deposits in the skin and subcutaneous lymph structures (whence 
farcy), and subsequent general infection. 

History. — Apsyrtus, a veterinary surgeon in the army of Con- 
stantine the Great, is credited with having made the first mention of 
glanders, under the name malts, a term which included, however, 
many other maladies. Vegetius also spoke of it, and Aristotle de- 
scribed it in asses. The disease had in former times a much more 
intense interest, in that to it, at various periods, wa£ credited the 
origin of syphilis, tuberculosis, scrofula, diphtheria, and pyaemia. 
The chief interest of glanders at the present day is in connection with 
diseases of the horse. 

Schilling of Berlin, and Muscroft of England, recorded accu- 
rately studied cases in 1821. Raver published the first monograph 
in 1837. Virchow contributed exhaustively to the pathology of the 
disease in 1855-63. 

Etiology. — The question as to the possibility of spontaneous origin 
was definitely denied with the discovery by Loffler and Schiitz (1882) 
of a specific bacillus — the Bacillus mallei — which these observers 
isolated, cultivated, and inoculated to reproduce the disease in the 
horse. 

The bacillus of glanders much resembles in form and size that of 
tuberculosis and leprosy, though it is shorter and more slender than 
either. It is immobile ; maintains its virulence desiccated for three 
months ; is readily colored with alkaline aniline dyes. It forms a 
characteristic colony on the surface of a potato, as a delicate yellowish,. 




GLANDERS. 91 

transparent coat, like a thin layer of honey, as early as the second 
day. Acting npon the method of Koch with tuberculin, Kalning, 
of Dorpat (1891), succeeded in extracting from cultures a product 
which he proposed to use in prevention and treatment. Most unfor- 
tunately Kalning fell a victim to the disease ; but his studies were 
taken up by Preusse of Dantzic, and Pearson of Berlin, who also 
succeeded in- extracting a dark-yellow, rather opaque, oily fluid of 
peculiar odor and neutral reaction, which they called mallein. and 
with which they obtained characteristic reactions in horses affected 
with the disease. 

The original seat of the disease in the majority of cases is the 
nasal mucous membrane, whence it may be disseminated through 
the bocly, to show itself more especially in the skin. The disease 
may be always recognized unmistakably by the examination of tissue 
exsected from the masses in the nose or in the skin. 
It is not readily recognized in fluid secretions, as 
it is easily destroyed by other bacteria. Field 
mice may not be used for the physiological test, as 
they are so exquisitely susceptible to the bacteria 
of septicaemia. The guinea-pig is to be preferred, 
as offering a much more exclusive soil. 

The disease is disseminated, as stated, through FlG - 84 ~ The bacillus 
the lymph vessels and also through the blood ves- ° g an ers 
sels, and is communicated to man either through a broken integu- 
ment, especially in the nose, during the process of currying or feed- 
ing, or other contact with diseased horses, especially in slaughtering, 
skinning, tanning. It is sometimes, but much more rarely, conveyed 
by the ingestion of infected meat — a mode of infection much more 
common in animals fed upon horse flesh, as in menageries. The 
most unsuspected and unavoidable source of infection, fortunately 
of most rare occurrence, is that which occurs in inhaling into the 
nose or open mouth the discharges from a horse's nose or mouth, as 
after the act of sneezing, snorting, coughing, etc. Exceptional cases 
have been recorded from drinking from the same pail used in water- 
ing horses, or from the common use of a handkerchief. The bacillus 
may also be lifted into the air and disseminated in the vicinity of the 
animal, especially in close apartments, stables, etc., whence it may 
be. inhaled into the respiratory tract of man. The disease has at- 
tacked and exterminated an entire family, man, wife, and four chil- 
dren, from the use of the same dish. Glanders occurs in the great 
majority of cases among hostlers, coachmen, drivers, stock-farmers, 
veterinary surgeons, butchers — that is, individuals who come in 
closest contact with the horse — and is, of course, much more common 
in the male sex. Bollinger found but six females in one hundred 



92 



GLANDEES. 



and twenty cases, and then in the case, of women compelled to sub- 
stitute men in the care of horses. For the same reason children are 
almost exempt from the disease. Man is much less susceptible to 
glanders than the soliped. 

The period of incubation after inoculation or inspiration varies 
from three to five days. It may extend to three weeks. 

Symptoms. — The disease manifests itself at the point of inocula- 
tion with redness, swelling, and pain, with speedy affection of the 
neighboring lymphatics. Constitutional signs occur in the course 
of a few days. They may even precede apparent changes in the 
wound. Chilly sensations with fever are attended with headache 
and prostration. Vague rheumatic pains, more especially in the 




Fig. 85.— Farcy buds in the skin. 



neighborhood of the joints, with local symptoms in the skin, may 
more distinctly announce the infection. Where or while tho local 
symptoms or the cutaneous signs are still absent, the disease simu- 
lates typhoid fever, for which it has often been mistaken. The 
character of the disease is, however, soon made manifest by the 
appearance of hard, red nodules, varying in size from a pea to a 
walnut, much resembling the eruption of small-pox. These nodules 
soon show softening of the centre and become converted into pustules, 
which burst, to give vent to thick, fetid pus. The nodules may 
increase to such magnitude as to form tumors — the so-called farcy 
buds — or, in the process of suppuration, constitute abscesses, the rup- 
ture of which leaves ulcers. These ulcers may destroy tissue to such 
depth as to expose tendons and bones. The process may extend 



GLANDERS. 93 

rapidly in twenty-four to forty-eight hours, or more slowly, to persist 
for three or four weeks. 

It is a fact, to be explained, perhaps, by the difference in the role 
of the nose in respiration, that while the manifestations in the skin 
are much less frequent and severe in the horse, symptoms on the 
part of the nose assuming in this animal so much greater prominence, 
the converse is true of man. Glanders in the nose is less frequent 
and severe in man than in the horse. Hauff declares that in more 
than half the cases in man the nose is not at all affected. Occurring 
in man, it shows the same symptoms as in the horse. The secretions, 
which may come only from the affected side, soon become changed, 
and the discharge from the nose shows the same thick, purulent, 
fetid matter as in the case of the horse. There may be usually seen 
at a glance, on inspection, such swelling and redness of the nose and 




Fig. 86.— Tubercular glanders in the nose. 

face as at times to simulate erysipelas. Sometimes tubercles may 
be discovered upon the alse of the nose. As in the horse, the affec- 
tion of the nose may show itself later in the course of the disease, 
often in the second or third week. , The mucous membrane of the 
eye, mouth, fauces, and of the whole respiratory tract may subse- 
quently become involved. The appearance of the membrane, with 
the tendency to haemorrhage, fetor oris, and dysphagia, may much 
resemble scurvy. There may be always observed in these cases the 
same involvement of the glands. The submaxillary and sublingual 
glands may suppurate to discharge externally. 

Affection of the bronchial mucous membrane is evidenced by 
harassing cough, with the profuse expectoration of the same fetid 
matter and the subsequent development of dyspnoea. Fever may 
be entirely absent, or may, in an individual case, assume prominence^ 



94 GLANDERS. 

with a temperature at 106°, and a feeble, irregular pulse like that of 
pyaemia. 

The chronic distinguishes itself from the acute form by its less 
intense manifestations and more protracted course. The affection 
of the nose, when present, does not vary in any essential from that 
already described. It is, however, less frequently present in man 
than in the acute form of the disease. There is the same puru- 
lent discharge with its excessive fcetor, the same swelling of the 
whole structure, while the nares are blocked with offensive 
crusts. Peculiar repulsiveness is added to individual cases in gan- 
grenous changes which may occur at the root of the nose. The 
manifestations in the skin are much more common, and upon these 
the diagnosis is, for the most part, established. Nodular masses 
may form anywhere over the body, more especially upon the ex- 
tremities, to discharge sanguineous serum and pus. Sometimes the 




Fig. 87.— Discharging cicatrices in the nose. 

affection is more superficial and shows itself in the form of blebs, 
which may simulate small-pox, chicken-pox, or pemphigus. 

The various complications of pysemia may subsequently ensue. 
Arthritis, serous or suppurative inflammations of the various serous 
membranes, with exudations, suppurating nodules, and masses in 
the muscles and bones, followed by extensive destruction of muscle 
and necrosis of bone, with deep erosions in the mucosse and subcu- 
taneous tissues, are common phenomena of marked cases. 

These various complications may follow each other rapidly in 
acute cases. The blood is quickly poisoned and the patient succumbs 
in the course of a week ; in the more subacute cases, in two to four 
weeks, with delirium and coma. The disease is much more pro- 
tracted in chronic cases. It may last for several weeks, months, 
-even years, and finally cause death by marasmus. There is during 
.all this time constant liability to the development of the acute form 
with its more rapidly fatal consequences. 



GLANDERS. 95 

The diagnosis is made to rest upon the nature of the avocation 
and the possibility of exposure. It is further determined by the two 
signs which have given names to the disease — to wit, the glanders, 
which finds its analogue in man in the term ozaena. It is to be 
remembered, however, that ozsena applies also to fetid discharges 
from the nose from various other causes, notably from syphilis. 
The second factor is the farcy, the nodular eruptions, abscesses, and 
ulcers found in the skin. The disease is recognized in its constitu- 
tional form by the signs of pyaemia — that is, by the chills, fever, and 
sweats, hebetude, delirium, and coma, together with the various 
metastatic depots. 

Syphilis may be separated in a doubtful case, ex juvantibus, as 
iodine and mercury have no effect upon glanders. 

Tuberculosis shows, as a rule, predominating signs on the part 
of the lungs ; and while it may affect the bones, as in a case of 
glanders, tuberculosis distinguishes itself by sparing the nose and 
skin, organs of selection in glanders. Small-pox is more uniform. 
The pustules of glanders appear in successive crops and rapidly 
ulcerate (Liveing). Pyaemia usually results from a single centre or 
depot, which may be recognized or discovered. Cryptogenetic cases 
may be distinguished at times only by the discovery of the specific 
micro-organism of glanders. 

The diagnosis of glanders really rests absolutely upon the re- 
cognition of the Bacillus mallei. Travers, long before the discovery 
of the specific micro-organism, established the diagnosis in doubtful 
cases by inoculation of goats and rabbits with matter discharged 
from some of the ulcers. Bollinger recognized the disease in the 
same way by the inoculation of a horse. The inoculated animals 
showed the special lesions and succumbed in the course of two or 
three months. Cornil succeeded in inoculating two of fifteen gui- 
nea-pigs by rubbing cultures into the intact skin of guinea-pigs. 
Washbourn and Schwartznecker established a diagnosis of human 
glanders by the isolation of the micro-organism, its cultivation, and 
the inoculation of animals. Jakowski called attention to the affec- 
tion of the testicle that occurs in these cases, and Strauss adopted 
the method of intraperitoneal injection as the quickest means of ab- 
solutely identifying the disease by implication of this organ. He 
was led to adopt this method on account of the difficulties attending 
the inoculation of animals with the products of the disease. Subcu- 
taneous injections in dogs do not always give definite results, and 
the inoculation of less susceptible animals — e.g., guinea-pigs — is 
unsatisfactory because of the length of time before death, twenty- 
five to thirty days. Field mice and marmots succumb in two to five 
days, but these animals are often difficult of access. 



96 HYDROPHOBIA. 

After the intraperitoneal injection of the discharges of glanders 
into the bodies of male guinea-pigs, there is observed first, as a pro- 
minent lesion, affection of the testicle as early as the second to the 
third day. The scrotum becomes tense, red, and shining, the epi- 
dermis desquamates. Suppuration speedily occurs, to perforate the 
integument, and in the pus is to be found the Bacillus mallei. The 
animal succumbs somewhere between four and fifteen days. The 
complication results also under subcutaneous injection, but much 
later — ten to twelve days. Loffler showed that it was not only the 
tunica vaginalis but also the parenchyma itself which showed nod- 
ules of the disease. The tunica vaginalis is covered with granula- 
tions, and by the third to the fourth day its layers are agglomerated 
by an exudation of pus rich with bacilli. A means of diagnosis is 
also offered with the injection of mallem (Preusse), which, as in the 
case of tuberculin in tuberculosis, produces a peculiar febrile reac- 
tion in glanders. 

The prognosis in a case of acute glanders is absolutely unfavor- 
able. The only possible rescue may result from the speedy destruc- 
tion and thorough annihilation of the first infection. Nearly all the 
acute and more than half of the chronic cases succumb to the disease. 

Prophylaxis. — Animals affected with glanders are to be isolated 
and killed. According to the report of the Berlin Health Office, 
1890, there were reported as affected with glanders thirteen hundred 
and thirty-seven horses. Eighty died ; ninety -three were killed at 
the request of their owners ; fifteen hundred and ninety-eight ani- 
mals were destroyed by the police — in all seventeen hundred and 
seventy-one horses perished. For those killed by the police there 
was paid by the State 459,834.08 marks indemnity. 

The cadaver is to be cremated or buried deep. Litter and fodder 
are to be likewise burned and stables thoroughly disinfected. All 
persons who have come in contact with infected horses should be 
warned of their danger. 

Treatment. — Local depots are to be treated thoroughly and 
promptly by the application of the actual cautery, strong carbolic 
acid, mineral acids, and corrosive sublimate, as in the treatment of 
anthrax. Chronic cases are to be supported with quinine, arsenic 
(Gamgee), and alcohol. 

HYDROPHOBIA. 

Hydrophobia (vdcop, water, cpofio?, fear) ; Greek, Xvffffa, rage; 
Latin, rabies ; French, la rage ; German, Wuth, Tollwuth, 
Hundswuth ; Italian, rabbi a; Swedish, Hundsjuka. — An intensely 
virulent infection of lower animals — dog, fox, wolf, cat, and skunk — 
in the order of decreasing frequency, communicable also to any ani- 



HYDROPHOBIA. 97 

mal (herbivora, fowl) and to man ; with the most variable, often the 
longest known period of incubation : distinguished by melancholia, 
terror, intense hyperesthesia of the medulla ; evinced as a spasm of 
the pharynx and larynx excited by attempts to swallow, or the pre- 
sence or the mere thought of liquids, a subsequent very short stage 
of paralysis, and almost inevitable death. 

The name is appropriate as expressing the most prominent symp- 
tom of the disease in man, but is inappropriate for the lower animals, 
as precisely this symptom, the fear of water, so obtrusive in man, 
is in them entirely absent. 

History. — It is strange that while the disease appears to have 
been known to the ancient Indians, Egyptians, and Israelites, Hip- 
pocrates makes no mention of it. Aristotle (322 B.C.) recognized it 
unmistakably in dogs : Ci Dogs suffer from rabies. This induces a 
state of madness, and all animals who are then bitten by them are 
likewise attacked by rabies. v Democritus considered it an inflam- 
mation of the nerves allied to tetanus. It is mentioned by Virgil, 
Horace, Ovid, Plutarch. Celsus, who first uses the word, speaks of 
it as the disease which vdoopcpofiiav Grceci appellant. 

The thorough elaboration of symptomatology in the lower animals 
as well as in man is chiefly due to English observers, especially 
to Youatt. Pasteur has connected his name with hydrophobia for 
all time, with his studies of prophylaxis — studies which established 
the nature of the disease as an infection whose symptoms are due to 
toxines from some as yet undiscovered micro-organism, and which 
fixed the fact of the first importance that rabies may in no case arise 
spontaneously,, but always and only from itself. 

Etiology. — Hydrophobia, like syphilis, is communicated by in- 
oculation through a broken skin ; and while it may be transmitted by 
any animal, it is actually communicated to man, in the great majority 
of cases (ninety per cent), by the bites of rabid dogs. 

The period of incubation in the dog varies usually from twenty to 
fifty days. It may vary from six to two hundred and forty days. 
It is certain that the animal may communicate the disease dur- 
ing the whole of the period of incubation. 

Escape may be due to accident. A bite after a recent bite is less 
dangerous. Saliva may have been wiped off in the first bite or ou 
the garments. The danger is illustrated by the part of the body bit- 
ten. In some American statistics quoted by Watson, of seventy-five 
cases the wound was in the hand forty times, on the face fifteen, in 
the leg eleven, and the arm nine times. Of four hundred and ninety- 
five cases collected by Bollinger, fifty-three per cent were bitten on the 
upper extremities, twenty-two per cent on the head and face, twenty- 
two per cent on the feet, and three per cent on the body and scrotum. 



98 HYDROPHOBIA. 

The cures of the charlatans by so-called madstones, etc. , often of 
great virtue in psychical cases, get their reputation from use in cases 
which have escaped real infection. 

Incubation. — The period of incubation of hydrophobia covers a 
point of the most intense and anxious interest. How long after a 
bite may an individual be considered safe ? This is the point in 
which hydrophobia differs from all known diseases, in that the 
period of incubation is so indefinite. In the majority of cases it is 
unusually long. Thus in sixty per cent the period of incubation va- 
ries from eighteen to sixty days, but in thirty-four per cent — that is, 
^ in a little over one-third of all the cases — the period is longer than 
two months. Cases are abundantly upon record of outbreak of the 
disease only after the lapse of three to six months, and there are 
cases upon authentic record where the only exposure which could 
have accounted for the disease occurred one or even more than two 
years before the attack. In a very small ratio of cases (six to 
eighteen per cent) the period of incubation is short, from three to 
eighteen days. Sometimes these alleged long periods, as well as 
cases without apparent cause, find explanation in a more recent in- 
fection which has been overlooked or forgotten. 

Variation in the time of outbreak has been distinctly observed in 
dogs. On one occasion six dogs bitten by one rabid animal showed 
signs of the disease respectively in twenty-three, fifty-six, sixty-seven, 
eighty-eight, one hundred and fifty-five, and one hundred and eighty- 
three days. 

From almost the first recognition of the disease in man attempts 
have been made from time to time to deny its existence altogether, 
and to consider hydrophobia a fright or a form of hysteria or of tet- 
anus. The fact, however, to say nothing of inoculation experiments 
in animals, that so many children under the age of five (nine per 
cent), and so many idiots and imbeciles, in whom the imagination 
could play no role, have succumbed to the disease, sufficiently dis- 
proves this view. The symptoms, as will be seen, distinctly differ 
from tetanus ; and the most that may be said of the hysterical origin is 
the fact that hysteria may simulate hydrophobia or any other disease. 

Notwithstanding the searching investigations at the hands of the 
best observers, especially in connection with the study of prophy- 
laxis, the cause of hydrophobia remains unknown. The analyses of 
chemistry have failed to disclose it. No specific micro-organism has 
been detected in the saliva or other fluid, and no distinct toxine has 
been eliminated from any of the secretions or tissues of the body. 
The poison is in all cases fixed, never volatile. It is produced only 
within the body, never outside of it. It acts in every respect like a 
chemical poison which is evolved from micro-organisms, but differs 



HYDROPHOBIA. 99 

from all the known poisons by the length of time in which it may 
remain innocuous in the body. Other secretions than the saliva, as 
well as the flesh of animals, as a rule fail to convey the disease. 

Various theories have been proposed to account for the long 
latency of the disease. The latest assumes that the poison lies latent 
at the wound, and from it chemical products are occasionally intro- 
duced into the blood, but are neutralized from time to time by the 
serum of the healthy blood, by the so-called protective proteids which 
act as antitoxines or antidotes, until finally they fail, to permit in- 
toxication. This view has now the best support. It accounts for 
the escape of so many cases with the simultaneous infection of 
others. It furnishes an explanation of the fact that the bite of a dog 
in the stage of incubation may be, but is not always, infectious. It 
accounts also for the favorable influence even to the prevention of 
the disease by the destruction of it at its origin. It allies it with 
other poisons, as in a case of septicemia, where the removal of a 
local depot may put a stop to a long train of septic signs. 

Morbid Anatomy. — The only changes which can be said to be at 
all characteristic are microscopic, and they are, with the rest, some- 
times entirely absent. The small vessels are dilated, and invested 
upon their exterior with leucocytes, which invade also the circum- 
jacent tissues. These changes are most marked in the medulla 
and the upper part of the spinal cord, as well as in the cerebral cor- 
tex, whence the symptoms of hydrophobia arise. Gowers observed 
this condition in seven of nine cases. Emigration or accumulation 
of leucocytes is at times so great as to fill up the whole space within 
the lymphatic sheath. These escaped and accumulated cells consti- 
tute what may be called miliary abscesses. In association with them 
are observed at times small haemorrhages, seldom large enough to be 
visible to the naked eye. This perivascular accumulation of leuco- 
cytes, especially in connection with the vessels of the medulla and 
cortex, constitutes the most constant and characteristic lesion of 
hydrophobia. Unfortunately, as stated, this sign, with all the rest, is 
sometimes entirely absent. 

Symptoms. — Hydrophobia is divided into three stages : the psy- 
chical, spasmodic, and paralytic. The disease is exceptionally an- 
nounced by changes at the seat of the wound, which, as a rule, has long 
since healed. The wound may open anew or become the seat of pain, 
itching, numbness, or other paresthesia. Sometimes pain irradiates 
from it in various directions. Sometimes the first feeling is in the 
nose or throat — a sneezing, a dryness or rawness, which is con- 
sidered " a cold." 

A peculiar state of depression and irritability soon sets in, 
sometimes suddenly with headache, anorexia, insomnia, anxiety. 



100 HYDROPHOBIA. 

Mental symptoms assume prominence according to the temperament 
of the individual. A man may deny the fact that he ever was bitten 
by a dog, while he is unable to divert his mind from the actual 
occurrence and the terrible consequences which are liable to ensue. 
The inquiry or suggestion of a thoughtless, meddlesome, or inqui- 
sitive neighbor will plunge the strongest man into melancholy or 
mania. The mental distress is, however, always an exaggeration 
of a state of apprehension, of a sense of impending danger or im- 
minent death ; and though a man may show, under the stress of this 
suffering, signs of insanity, there is no time when he may not be 
^recalled to himself by a right address. A patient affected with the 
first stage of hydrophobia presents a pitiful picture. He sits quiet, 
apparently listless, his whole mind intensely concentrated upon the 
one thought from which no appeal or address may really divert him. 
It is only in the very first hours of the attack that he may find relief 
in walking about or in change of scene. He soon becomes exhausted, 
and sits with an expression of intense anxiety to which he makes 
total surrender. At the same time the special senses are keenly 
alert, so that a flare of light, a draught of air, a noise, may produce 
intense excitement. The very first day shows the characteristic sign 
of the disease — the fear of water. The patient suffers with thirst, 
but is unable to allay it. He may make the attempt, may succeed 
at first in swallowing a mouthful or two, but soon abandons it, 
either on account of the intense suffering which ensues, or from the 
fear of its certain following. An unmistakable sign of the disease 
is the occurrence of burning, more especially a sense of tightness or 
constriction, of the larynx. The fear of water is the fear of exciting 
spasm of the larynx, and the reflex excitability of the larynx be- 
comes so intense that spasm is later precipitated by the sight, the 
sound, or the mere thought of water, even by the mere sight or 
touch of a smooth or cold surface. A coachman under Watson's 
observation had to desist from sponging himself, according to his 
habit, with cold water, though he said he " could not think how he 
could be so silly." Frequent sighing is a common sign at the in- 
ception of the disease. 

The first stage usually lasts about twenty-four hours, when the 
second stage, the spasmodic or true hydrophobic stage, sets in. 
This stage is characterized by an exaggeration or an intensification 
of the spasmodic contraction of the larynx. Every attempt to 
swallow is attended with frightful anxiety. The contraction is so 
powerful as to lead to dyspnoea with maniacal excitement. The 
patient may strike about in every direction, roll his head from side 
to side, while the mouth opens and closes convulsively, sometimes 
with snapping sounds, whereby wounds are occasionally inflicted 



HYDROPHOBIA. 101 

upon ministering hands ; and the disease has actually been conveyed 
in this way. These convulsive seizures gave rise to the stories that 
hydrophobic patients bite and snap like dogs, and led, through the 
fear which they excited, to the cowardly assassination of patients by 
shooting them down — a practice still in vogue on the confines of 
Austria — or by smothering them between feather beds. The parox- 
3 T sms seem all the more dreadful because they are attended with the 
escape of glutinous, foaming saliva, which is sometimes ejected with 
great force in every direction. Inspiration is also attended with 
gaping and sighing and various sounds, sometimes simulating the 
bark and howl of dogs. These things occur in paroxysms, in the 
interval of which the mind is clear, though sometimes, in highly 
nervous temperaments, it may be excited to show more persistent 
hallucination. The pulse is quickened and rendered irregular, but 
with all the struggle there is, as a rule, but little elevation of tem- 
perature. The employment of any forcible measures of restraint 
aggravates the explosion. 

The second stage lasts, as a rule, from one to three days, rarely as 
long as four days. The patient now becomes gradually exhausted. 
Paroxysms occur, but they are less intense. The extreme anxiety of 
mind is diminished; there are intervals of nearly complete tranquil- 
lity. It is plain to see, however, that while the breathing is easier 
and the explosions less severe — there may be even ability to swallow 
— the patient becomes more and more prostrated and reduced. The 
strong man is broken. The heart's action is weak, the pulse flutters, 
the surface is covered with a cold sweat. The movements of the 
body are so much enfeebled as to present the appearance of para- 
lysis ; hence this third stage has been characterized as the stadium 
paralyticiim. Death, which may occur suddenly in a convulsion 
or from asphyxia, usually does occur quietly from failure of the 
heart. 

Hydrophobia is an exquisitely acute infection. However long the 
period of incubation, the whole duration of the disease proper is 
measured in a few days. Eighty -two per cent of cases perish in from 
two to four days. Individual cases may succumb in two or may 
last as long as five or six days. 

The diagnosis is generally easy, and rests chiefly upon the height- 
ened reflex of the medulla, as manifested in spasm of the muscles of 
deglutition and respiration. 

The disease is differentiated from tetanus by its much longer 
period of incubation. Tetanus occurs in from three to ten days after 
the wound or injury. Tetanus usually begins with trismus, and is 
often attended with opisthotonos. It lacks the laryngeal symptoms 
and spasms of hydrophobia. It lacks also the psychical exaltation 



102 HYDROPHOBIA. 

and mental anguish of hydrophobia. Tetanus may also be distin- 
guished by its special micro-organism. 

The disease is often distinguished with great difficulty from the 
imaginary condition known as lyssophobia, or fear of hydrophobia. 
These cases have a common origin, though in the one case the wound 
comes from a non-affected animal. It might be imagined that lysso- 
phobia occurred more frequently in nervous subjects or in women. 
This is not the case. The strongest men have suffered, and not 
infrequently actually succumbed to fright or fear of hydrophobia. 
Some of these cases have been rescued by knowledge of the fact that 
the animal was not rabid ; hence the advisability, when possible, of 
^secluding the animal, that the existence or course of its disease may be 
observed. The fact that the animal recovers at all almost necessarily 
excludes hydrophobia. Abundant cases are recorded where informa- 
tion of the recovery of the animal, or the sight of the animal itself, 
has allayed the most intense nervous symptoms. 

The prognosis is fatal. It is commonly said that the physician 
that cures is death. Bollinger goes so far as to say that the cases of 
alleged recovery may be invariably found to be due to some other 
disease, or to the fact that the animal was not rabid. Yet it must be 
admitted that dogs have recovered from the disease. Law mentions 
eight such cases, two of which were attested by successful inoculation 
of other animals. The possibility of spontaneous recovery may there- 
fore be entertained in man. Wounds on the face are, as stated, al- 
ways the most serious. Bouley declares that ninety per cent of these 
cases are followed by hydrophobia, whereas the mortality from 
wounds of the hands is sixty-three per cent, of the lower extremities 
twenty-eight, and of the upper extremities twenty per cent. Many 
cases are certainly rescued by prompt treatment. Bollinger quotes 
in proof the following statistics in France : Of two hundred human 
beings bitten by rabid animals, one hundred and thirty-four were cau- 
terized. Of these, ninety-two (that is, sixty-nine per cent) remained 
healthy, while forty -two (that is, thirty-one per cent) died of hydro- 
phobia. Of those not cauterized, eighty- three per cent succumbed to 
the disease. In one case sixteen persons and one ass were bitten by 
the same animal. The human beings were cauterized and rescued 
without exception ; the ass, which received no treatment, died of 
the disease. 

The only true prophylaxis is the muzzle, which renders all other 
prophylaxis superfluous. But for various reasons, including a kind 
of sentimentality, the process of muzzling had never been rigidly en- 
forced outside of a military country like Prussia. The disease, which 
was formerly common in Prussia, was actually extinguished, as stated, 
for nine years by the rigid enforcement of universal muzzling. Hoi- 



HYDROPHOBIA. 103 

land secured nearly the same exemption in the same way. The num- 
ber of dogs may be limited by being subject to higher taxation. 
Every dog should have a known master. Suspected dogs must be 
carefully confined, and for as long a period as six months. Dogs im- 
ported from countries of lax laws in this regard should be quaran- 
tined for six months. Actually rabid dogs or other animals that 
need not be preserved to determine the condition of human beings or 
other animals attacked, should be killed at once. Filing the teeth, 
or attachment of blocks of wood about the neck, confinement by 
chains, attempted prophylaxis by injection of virus, are all means too 
unreliable for practice. 

Treatment consists in the destruction or elimination of the poison 
in the wound. Absorption should be first prevented where practi- 
cable, as on the extremities, by a ligature above the wound. A piece 
of cord or handkerchief should be firmly twisted about the limb with 
a piece of wood. Where it may be done, the patient should with- 
draw the poison from the wound by suction. With proper precau- 
tions this act may be substituted by another person. The act of 
suction is, however, dangerous in cases of carious teeth, or wounds in 
the gum, cheek, or other parts of the mouth. The operation may be 
done, nevertheless, if the individual take the precaution to rinse the 
mouth thoroughly, after every suction, with carbolic acid. Hertwig 
found that the virus of hydrophobia applied to the mucous mem- 
brane of the mouth and digestive tract was entirely innocuous. This 
process, which has been resorted to from the most ancient times, has 
never yet proven infectious. In the first decades of the present cen- 
tury, in Lyons, certain women — Hundsdugnerinnen — pursued this 
business as an avocation. They received ten francs for the first, and 
five for each succeeding suck. On the surface of the trunk and some 
parts of the face the poison may be exhausted by cups. Immedi- 
ately after suction the wound should be cauterized. Youatt relied 
entirely upon such a superficial caustic as the nitrate of silver. As 
he was himself bitten seven times, and operated on four hundred 
persons, only one of whom died, and that one, as he declared, from 
fright, this caustic may be considered sufficiently strong if applied 
immediately. Caustic potash burns deeper. The actual cautery, as 
from a poker, a nail, the galvano-cautery, brought to a white heat, 
would certainly destroy the poison more effectually. Where wounds 
are very extensive or numerous the effect may be best accomplished 
with stronger solutions, 1 : 500 or 1 : 1000, of corrosive sublimate. 
Extensive laceration of extremities may require amputation. 

Psychical treatment is of supreme importance. Romberg first 
advised the necessity, on the part of the attendants and friends, " to 
preserve a calm demeanor, to avoid all allusion to the previous in- 



104: HYDROPHOBIA. 

jury, and to appear cheerful." To secure diversion without effort or 
remark is an essential factor in the relief of suffering, at least. The 
intense reflex excitability of the medulla is best met by seclusion 
in a quiet and rather dark room. The exhibition of cases as curiosi- 
ties, or as objects of morbid sympathy, is a cruelty, if not a crime. 
Frequent warm baths, where at all permissible, as at the very start, 
tend to allay excitability and spasm. Very soon, however, resort 
must be had to anodynes and ansesthetics. Violent cases may require 
the use of chloroform. The same object may be at first obtained 
with chloral. The various remedies recommended as specifics — 
curare, calabar bean, pilocarpine —have proven useless, except in al- 
laying spasms. The use of animal poisons has proven equally futile. 
Watson speaks of cases treated with the virus of snake bites. One 
man was bitten by nine vipers without effect. Opium is the best 
shield. Sooner or later resort must be had to morphia in the later 
course of the disease, preferably subcutaneously, with a view at least 
to secure euthanasia. 

With this history hitherto, it may be appreciated with what accla- 
mation was hailed the claim by Pasteur of the discovery of a means 
of preventing the disease by the use of attenuated virus. It had 
been always known that the disease expends its main force upon the 
medulla. Whatever lesions are encountered in the disease are seen 
here. 

So soon as Pasteur had determined that the virus of hydrophobia- 
comes to be located in the central nervous system, especially in the 
spinal cord, he began his experiments with this substance to secure 
attenuated matter. He found that a continued inoculation of the 
virus from rabbit to rabbit increased its virulence to such degree that 
after about twenty-five generations he got a virus which showed its- 
effect after an incubation of but eight days. In twenty -five genera- 
tions further the period of incubation was limited to seven days. This 
virus was taken as a so-called virus fixe, as a basis substance for 
protective inoculation. Pasteur discovered that desiccation of the 
medulla from such an animal in sterilized glass vessels in which had 
been put pieces of caustic potash brought about a gradual reduction 
of virulence. The medulla became less and less poisonous. The 
drying process was continued, until, after two weeks' desiccation, it 
was entirely innocuous. Injections were now made with an emul- 
sion of the non- virulent medulla, and were followed up with emul- 
sions of medullas of increasing violence up to those which had been 
dried but one or two days. Dogs so treated were immune to infection 
with fresh hydrophobic matter. 

In the treatment of the hydrophobia of man, Pasteur began with 
weaker preparations — to wit, with the medulla. of the rabbit after 






TETANUS. 105 

fourteen days' desiccation, and increased on the following days up to 
that of the fifth day, whereby immunity or protection was secured. 
The attempt to use stronger preparations in a shorter time, in pro- 
tection against the more dangerous and extensive laceration of Avolf 
bites, had to be discontinued. This treatment has been used now in 
thousands of cases ; and while it cannot be said to have furnished 
perfect results, as a number of cases thus treated have nevertheless 
succumbed to the disease, it must be admitted that the majority of 
cases thus treated have been rescued from the horrors of hydro- 
phobia. The statistics of the Pasteur Institute from 1886 to 1891 show 
a continued decrease of deaths from 0.91 per cent in 1886 to 0.25 per 
cent in 1891. In 1891 as many as 1,464 patients passed under treat- 
ment. 

These results, brilliant as they are, are eclipsed by the report of 
Tizzoni and Centanni, who make the extraordinary claim to be able 
not only to confer immunity, but to actually cure hydrophobia, 
even after the disease has developed, by the injection of the blood 
serum of animals rendered immune to the disease. The immunity is 
conferred by the inoculation of an emulsion of spinal cords (rabbits) 
attenuated by partial digestion in artificial gastric juice (peptones). 
Poppi finds that the matter used by Pasteur may be further attenu- 
ated, by dilution and heat, to act not only like a veritable vaccine in 
protection against the disease, but also to cure it. These claims have 
not yet been conclusively established. 

TETANUS. 

Tetanus (reravos, tsivoj, to stretch) ; trismus, lockjaw, opistho- 
tonos {pniade, backward, teivgq, to stretch) ; German, Wundstarr- 
krampf. — A grave, often exquisitely acute infection, caused by the 
tetanus bacillus, introduced through a wound or some break of the sur- 
face ; characterized by excessively heightened reflex under the action 
of toxines which induce spasmodic contraction of the voluntary mus- 
cles, first and especially, of the jaw (trismus, lockjaw), face, and neck, 
and extensors of the spine (opisthotonos); of short duration, often of 
rapidly fatal termination. Among the larger animals the horse, 
sheep, and goat are especially liable to the disease. 

History. — The clinical features of tetanus are so coarse and ob- 
trusive as to have been remarked in the most ancient times. Some 
of the finest descriptions of Aretseus were based upon observations 
of tetanus. " In all the varieties," he says, "there is pain and ten- 
sion of the tendons and spine, and of the muscles connected with the 
jaws and cheek, so that the jaws could not easily be separated, even 
with levers or a wedge. " Hippocrates devoted a whole section to 
its treatment, and certainly appreciated the gravity of the disease. 



106 TETANUS. 

" Such persons/ 7 he says, " as are seized with tetanus die within four 
days, or if they pass these they recover/ 7 

Most of the contributions of later times have been presented by the 
surgeons, Laurent, Larrey, etc. Curling wrote his famous " Treatise 
on Tetanus 77 (Jacksonian prize essay) in 1834; Rose (E.) made the 
most valuable clinical contribution of modern times to the " Hand- 
buch der allgemeinen und speciellen Chirurgie 77 (Pitha und Billroth, 
Bd. i., Abtheil. A, 1870). Mcolaier discovered the bacillus of tetanus 
in the soil in 1885. Rosenbach demonstrated it in man in 1886. Ga- 
gliardi reported the first cure of tetanus in man by the subcutaneous 
injection of the antitoxine of Tizzoni-Centanni in 1892. 
, Etiology. — Tetanus may occur in consequence of any kind of 
wound, but does occur much more frequently after contused wounds 
with penetration of foreign bodies. It is, therefore, frequent after 
gunshot wounds, and is especially frequent in wounds of the extremi- 
ties. Wounds of nerves are also attended with special liability. Tet- 
anus may follow a lesion as trivial as the extraction of a tooth, a vene- 
section, the sting of an insect, a simple scratch of the surface, the 
application of a blister, a slight wound of the foot, as from a nail in 
a shoe. It occurs not infrequently in the new-born from lesions of 
the umbilical cord, and has been repeatedly observed after a wound 
of the cervix uteri, as after parturition. The intrusion of a splinter 
of wood, the lodgment of a fish bone in the throat, have broken the 
surface sufficiently to introduce or give entrance to the cause of the 
disease ; and as the cause comes from without, tetanus occurs, in the 
great majority of cases, in wounds of the extremities. Curling found 
one hundred and eleven of one hundred and twenty-eight cases on 
the extremities, and Thamhaym, in three hundred and ninety-five 
cases, found the locality of the injury in the hand and finger one 
hundred and nineteen times. 

Tetanus is a rare disease. Rose states that the mortality of teta- 
nus in Berlin was but 0.04 per cent, and this included two hundred 
and sixty-six cases in new-born infants. 

The disease is most frequent in hot countries. Aside from attack 
of the new-born, the period of greatest liability is between ten and 
thirty. 

The tetanus bacillus is a delicate rod, a little longer than the 
bacillus of mouse septicaemia. It occurs in irregular masses in the 
affected tissue, and is recognized by the characteristic development 
of its spores. One end of the bacillus swells to show an oval, 
sharply defined, shining spore, and present the appearance of clock- 
bell strikers, drumsticks, or, better, pins. This spore formation oc- 
curs in great abundance in the body of the animal, as well as in 
artificial cultures. The bacilli are easily colored with methyl blue 



TETANUS. 



107 



.and f uchsin. Artificial culture is difficult. The bacillus is strictly, 
i.e., an obligate anaerobe, so that in artificial culture particles of 
infected matter must be introduced into the deeper layers of blood 
serum to secure growth. The culture is so commonly contaminated 
as to require often subsequent separation to obtain it pure. 

Brieger (1887) obtained from sterilized cultures of the tetanus 
bacillus a toxine, which in mice, in the smallest doses, produced 
"the typical symptoms of trismus and tetanus, with fatal termination. 
Besides this body, Brieger eliminated various toxalbumins with spe- 
cific properties. 

The bacilli and spores of tetanus are so widely disseminated in 
■soil and dust as to be almost ubiquitous. They abound most on 
the surface of inhabited soil, and are not entirely absent in uncon- 
taminated virgin soil. The rub- 
bish and dust of streets and houses 
-are soils of predilection. The 
wide dissemination of the parasite 
accounts for the cases of apparent 
►spontaneous or idiopathic teta- 
nus, while the fact that the free 
►access of oxygen prevents its 
growth furnishes explanation of 
the comparative rarity of the dis- 
ease and the greater liability of 
penetrating wounds. 

The period of incubation varies 
from one to two weeks. 

Symptoms. — The disease be- 
gins, as a rule, with spasm of the 

muscles of mastication. Contraction of the masseters locks the 
jaws, to produce the condition known as trismus, lockjaw. Con- 
traction of the muscles of the neck occurs at the same time, or may 
precede the contraction of the jaws. Rose declares that the contrac- 
tion of the masseters may be felt by the insertion of the finger within 
the mouth, and that the stiffness of the muscles of the back of the neck 
is best recognized, as in cerebro-spinal meningitis, by attempts to lift 
the body by the head. The affection of the muscles of the face soon 
produces a peculiar physiognomy. The lips are usually stretched 
over the closed teeth, to produce the characteristic smile, the 
risus sardonicus,so graphically described by Hippocrates. Fagge 
speaks of the case of a girl who was reprimanded by her mother on 
account of a singular grinning expression of the face, over which 
she had, of course, no control. This alteration of the physiognomy 
gives to .the patient the appearance of age. Farr says a man aged 




Fig. 88.— Bacillus of tetanus. 



108 TETANUS.- 

twenty-six was taken fox* sixty. The disease begins usually mildly,. 
and increases gradually and progressively. There is in association 
with the stiffness of the neck or diminished mobility of the jaw some 
difficulty of deglutition. The muscles are affected from above 
downward. 

The spasm extends to involve the muscles of the back. Implica- 
tion of the groups of great muscles in the spine soon distorts the 
body. The whole trunk is stiffened like a statue (orthotonos), or is 
more frequently arched, with its convexity upward, so that the body 
may rest upon the back of the head and the heels — opisthotonos. 
The forearms and hands are spared for a long time. Motion, either 
active or passive, is soon inhibited or lost altogether under the board- 
like indurations of the muscles. During these states of rigidity 
convulsive attacks occur with shocks like strokes of lightning. 
They show themselves in consequence of effort, even of involuntary 
effort, or as the result of any outside irritation, and express the in- 
tense reflex excitability of the spinal cord. In the interval the body 
assumes the position of rigidity from which it has been distorted by 
the violence of the spasm. The suffering of the patient at this time 
is indescribable. The spasms are attended with excruciating pain. 
The mind is perfectly clear, but is weak from loss of sleep and anx- 
iety. The patient may not satisfy either hunger or thirst, on account 
of locking of the jaws. The opisthotonos prevents a proper decubi- 
tus. Individual muscles, especially the recti abdominis, have actu- 
ally ruptured under the powerful contraction, to discharge masses of 
blood at their divided ends. Difficulty of breathing, cyanosis, a 
sense of distress and danger, with lancinating pains at the bottom 
of the chest, indicate the spasmodic contraction of the diaphragm. 
Fever may be entirely absent. There is generally some elevation of 
temperature, which is liable to sudden exaggeration, often without 
discoverable cause, probably due to the influence of the nervous sys- 
tem. Extreme elevations of temperature to 110° or 112° are pre-ago- 
nal. Sometimes there is an elevation of temperature post mortem. 
The skin is usually covered with sweat — a point often of diagnostic 
value. The bowels are constipated. There is often suppression and 
more frequently retention of urine. 

The diagnosis largely rests upon the early appearance of trismus. 
Lockjaw from sore throat, mumps, synovitis, rheumatism at the 
temporo-maxillary articulation, should be easily distinguished by the 
most superficial examination. The feel of the rigid masseters inside 
the mouth, and the associate stiffness at the back of the neck, speedily 
dissipate doubts. Hysteria and hystero-epilepsy may show the typi- 
cal opisthotonos of tetanus, but hysteria is, as a rule, unattended 
with trismus ; and when trismus is simulated by the fixation of the 



TETANUS. 109 

jaws, hysteria is recognized by the fact that the intervals of attack 
are irregular and always entirely free from spasm or pain. 

The regular invasion of tetanus from above downward, first of 
the muscles of the face and neck, later of the trunk, distinguishes the 
disease from the spasmodic contractions of spastic myelitis. Cerebro- 
spinal and basilar meningitis, which have, in common with tetanus, 
stiffness of the neck and opisthotonos, almost never show trismus. 
They have also a different origin and history — i.e., epidemic, tubercu- 
lous — with associated symptoms, vomiting, headache, hyperesthesia, 
herpes, etc. , not seen in tetanus. 

Tetany is distinguished by its typical spasms of days' and some- 
times weeks' duration, and absolute intermissions ; by the peculiar 
•contraction or position of the hand, which may be called out by long- 
pressure upon the nerves or arteries of the arm — the so-called Trous- 
seau phenomenon ; by the frequent laryngo-spasm ; and by the in- 
creased mechanical and galvanic excitability of the motor nerves. 

Hydrophobia, which has. in common with tetanus, spasm of the 
muscles of deglutition, is distinguished by the much shorter period 
of incubation, by the trismus and opisthotonos of tetanus, and by the 
psychical exaltation and anxiety of hydrophobia. 

By far the most important question in differential diagnosis 
concerns the recognition of poisoning by strychnia, which is most 
closely simulated by the effects of the toxines of tetanus. This 
diagnosis rests upon the following points : 1. The history of origin, 
where it may be obtained. 2. The existence of a wound. 3. The 
period of incubation. Signs of strychnia poison supervene at once. 
Tetanus begins with trismus and gradually descends, sparing, as 
a rule, except in children, the arms and hands ; strychnia often 
shows its first signs in irritation of the stomach and in the affection 
of the muscles, seizes by preference upon the extremities. In tetanus 
there is persistent rigidity; in strychnia poisoning there are intervals 
of absolute relaxation. Thus, in the interval between the paroxysms 
the mouth remains closed in tetanus, but may be freely opened in 
strychnia. The reflex spasms of tetanus occur later in the course of 
the disease and increase in intensity, while those of strychnia occur 
at once, intense from the start. Strychnia poisoning is quickly 
terminated by death or recovery. Tetanus may be protracted into 
days and weeks. Golding-Bird reported the case of a boy affected 
with tetanus, with spasms for fifty-one days, with subsequent per- 
sistent rigidity, and death on the one hundred and seventh day. 

Eiselsberg establishes, as a difference between tetanus and other 
wound infections, the fact that in tetanus local wound reactions are 
entirely absent. So-called cases of rheumatic tetanus are, therefore, 
really of traumatic origin. 






110 TETANUS. 

The prognosis is exceedingly grave. Death may occur in any 
attack of convulsions. The heart has actually, under observation 
suddenly ceased to beat. Death occurs, as a rule, before the end of 
the first week, so that, as Hippocrates said, "patients die within four 
days, or if they pass these they recover." In exceptional cases, 
however, the fatal termination may not occur for three weeks. The 
disease rarely lasts longer in childhood than two or three days. The 
prognosis is so grave in the new-born that, as Bauer declares, the 
occasional cases of recovery have been looked upon as being probably 
errors in diagnosis. According to Bichter six hundred and thirty- 
one of seven hundred and seventeen military cases — i. e. , eighty-eight 
per cent — were fatal. 

According to Rose sixty- three per cent of all cases die within the 
first five, and eighty-eight per cent within the first ten days. The re- 
lief of the later periods is probably to be explained by elimination of 
the toxines. Rigidity may persist for some time, even for months, 
after recovery. The ability to sleep is always a favorable sign. 

Prophylaxis. — In prevention of tetanus it is to be emphasized 
that the minutest wounds soiled with earth, dust, or foreign bodies, 
as splinters, are to be scrupulously cleaned and disinfected. Patients 
themselves are to be isolated from other surgical cases. 

In prophylaxis of the new-born it must be observed that the 
wound at the navel is attended with the utmost care. The aseptic 
treatment already recommended by various authors meets thus with 
scientific justification. For all the investigations concerning the 
origin of the tetanus bacillus- demonstrate that it has an unusually 
wide ectogonous dissemination. Unclean hands, the use of ban- 
dages not sufficiently aseptic, and the raising of dust in the cleaning 
of the puerperal room, sufficed, in the observations of Beumer, to 
convey the infecting agent. 

Treatment. — As in hydrophobia or other disease characterized 
by excessive hypersesthesia of nerve centres, the patient should be 
kept perfectly quiet. He should be put in a dark room and isolated 
from curiosity or officious or meddlesome ministration. The most 
absolute silence should be enjoined, on the part of the patient as well 
as the attendants. On account of the locked jaw the food should be 
fluid, but should be as nutritious as possible. Milk, soft-boiled egg 
diluted with hot water, nutrient soups, stimulants, wine, whiskey, 
brandy, should be regularly administered. Where the act of deglu- 
tition excites spasm, the patient may be anaesthetized and, according 
to the suggestion of Rose, fed through a tube, which may be, as in 
the case of insane or refractory patients, inserted through the nose. 
Foreign bodies should certainly be immediately extracted, irritated 
nerve trunks excised. Angry wounds, "festering sores," may be 



TETANUS. 1] 1 

treated with the powerful antimycotics, carbolic acid, corrosive 
sublimate, or with the actual cautery. More extensive exsections, 
more especially amputations, are surgical barbarities of the past. 
Spasmodic contractions are best relieved by the administration of 
anodynes. Opium, on account of its associate discomfort and 
distress, is better substituted in our day by chloral. A large dose 
— one drachm at first — may be followed by smaller doses, fifteen to 
thirty grains, every hour or two, or as often as necessary to subdue 
spasm. Calabar bean and curare have been administered with 
success in individual cases, sometimes of questionable diagnosis ; but 
these remedies have failed, as a rule, to secure other than temporary 
relief. 

Bacelli recommended the injection of one centigramme of car- 
bolic acid every hour or two until the spasms entirely ceased. 
Caliari claims to have cured a case in this way. 

The hope of successful treatment lies in the use of the antitoxines 
derived from the blood serum of animals — dogs — rendered immune 
to the disease, or from the bodies of the bacteria themselves. 
Tarufri has already recorded a sixth case rescued in this way. 
The treatment consists in the injection of the tetanus antitoxine 
obtained from the blood of a dog rendered immune to the disease. 
Twenty-five centigrammes are injected twice a day. Such improve- 
ment occurs in the course of a week as to render the further use of 
the remedy unnecessary, and the treatment is usually concluded 
with the hydrate of chloral. 

Unfortunately some of the best observers do not confirm these 
conclusions. Kitasato was not able to get immunity by tolerance, 
nor by the use of filtrates attenuated by heat. Rabbits were ren- 
dered immune in forty per cent of cases with the trichloride of 
iodine, but the immunity was lost in the course of two months. Im- 
munity is conferred upon mice by the injection of the serum of im- 
munized rabbits, but this immunity is lost in forty to fifty days. 
The fowl is by nature immune to tetanus, but the blood of the fowl 
does not confer immunity upon other animals. 

By the second method Ehrlich. Brieger. and Wassermann utilize 
the antitoxines developed by the bodies of the bacteria themselves, 
after the manner of Koch with tuberculin. These antitoxines or 
protective bodies are to be obtained in the milk of parturient animals 
previously rendered immune in pregnancy by inoculation of an 
attenuated culture which is gradually increased in virulence. The 
protective principle remains in the whey after coagulation and sepa- 
ration of the casein, so that it may be preserved indefinitely. Some 
of the most sensitive of the lower animals — mice, goats, etc. — have 
already been protected in this way, but up to the time of the pre- 



112 WHOOPING COUGH. 

sent writing the accounts published of work with man have not 
been satisfactory. 

WHOOPING COUGH. 

Pertussis (per, intensive, tussis, cough) ; tussis convulsiva ; Ger- 
man, Keuchhusten ; French, coqueluche [used also for influenza] 
(from coqueluchon, a cape worn by patients). — An acute infection 
of childhood, distinguished by paroxysms of cough in rapid series, 
threatening suffocation, terminated by a long-drawn, audible (whoop) 
inspiration. 

The name is derived from the fact that the cough is distinguished 
by a prolonged, forcible, and audible inspiration through a spasmod- 
ically contracted glottis. But many cases of whooping cough are 
without this characteristic sound, and, where different stages of the 
affection may be recognized, the sound is absent during the whole of 
the first and most of the last stage. The cough consists of a series 
of short, sharp explosions, spasmodic in their character ; a series of 
expiratory efforts without stop to catch the breath, until finally, after 
the lapse of from fifteen to sixty seconds, at the point of exhaustion 
occurs this prolonged, audible inspiration. It is the series of explo- 
sive coughs in quick and uninterrupted sequence, the short, sudden 
cough, the staccato cough, which marks whooping cough. 

History. — The origin and home of whooping cough are involved 
in obscurity. According to Mason Good the disease was known to 
the Greeks ; but their descriptions, as well as those of subsequent 
writers, do not distinguish it, strange to say, from other spasmodic 
or catarrhal affections. All authors agree that the disease was cer- 
tainly definitely described by Baillou (Paris, 1578), who spoke of it 
as a well-known malady. 

Etiology. — Whooping cough is an infectious disease, because it is 
•contagious and prevails as an endemic and epidemic ; because, also, 
of the absolute immunity which one attack confers. Rare as are 
second attacks of scarlet fever, measles, or small-pox, still more rare 
are second attacks of whooping cough. With the other infections it 
attacks preferably the age of childhood. Facts which have been 
taken to militate against the views of its infectious nature are ab- 
sence of fever and indefiniteness of duration. Facts which refute 
the idea that pertussis is a neurosis are, first, origin and dissemina- 
tion by contagion ; second, appearance as an epidemic ; third, im- 
munity conferred by single attack. Neuroses belong to individuals 
and not to numbers. They show no relation to others and have con- 
stant tendency to recur. Proof of contagion is furnished by the at- 
tack of wet-nurses and nurses generally, instances of which are no- 
ticed in every epidemic. 



WHOOPING COUGH. 113 

The period of preference as regards age is from six months to six 
years. Sucklings, because of natural immunity, are rarely attacked. 
Susceptibility diminishes at six and is nearly annulled at ten j'ears. 
Yet cases are on record where the disease has occurred in infancy 
and advanced life. From some inexplicable reason the female sex 
suffers most, in the proportion, according to nearly all authors, of 
five to four. The disease is not only more frequent but also more 
severe in girls. Measles, pregnancy, and the puerperium predispose 
to pertussis. The contagion is conveyed directly. 

The contagious principle exists in the sputum, hardly possibly in 
expired air which contains no sputum. It is a contagium halituo- 
sum. The great botanist Linnaeus, nearly two centuries ago, ex- 
pressed the belief that whooping cough was due to a contagium ani- 
matum, which he thought would be found to be the eggs of insects. 
The principle is thoroughly accepted in our day. 

Afanassieff succeeded -in isolating from the sputum of whoop- 
ing-cough patients a short, thick bacillus, which he cultivated upon 
beef peptone and agar. The bacillus differs in important particulars 
from forms hitherto described, and gives rise, when introduced into 
the trachea or lungs of dogs and rabbits, to symptoms simulating 
whooping cough and to lobular pneumonia. Ssemtchenko, after 
considerable experimentation, reached the conclusion that the bacillus 
of Afanassieff is specific. It may be found in the sputum as early 
as the fourth day of the disease. It multiplies in the body, and as it 
increases, the disease diminishes in severity. It disappears with the 
resolution of the disease, or when the paroxysms are reduced to two 
to four daily. In the presence of complications, especially catarrhal 
pneumonia, it increases in the sputum. Thus this bacillus is of 
value not only in etiology and diagnosis, but also in prognosis. 
These conclusions have, however, not yet met with universal ac- 
ceptance, as the observations have not been sufficiently verified. 
Renewed interest attaches to this .bacillus of Afanassieff with the 
discovery by Griffiths of a ptomaine or toxine in the urine of 
whooping-cough patients. Griffiths claims to have established the 
fact experimentally that an absolutely identical toxine is developed 
by this bacillus. The toxine is not found in any case of normal 
urine, nor in that of any other disease than pertussis. 

There is now scarcely room for doubt that pertussis is a mycosis 
whose toxines have a special action upon that part of the nervous 
system which presides over cough — to wit, the centres of the superior 
laryngeal and vagus nerves. In this way, in our day, the mycotic 
has displaced the neurotic theory. 

The contagious principle is not often disseminated without direct 
8 



114 WHOOPING COUGH. 

exposure to the disease. Very slight isolation secures exemption 
from the attack. The bacillus has no great tenacity of life. 

Whooping cough occurs with special frequency during con- 
valescence from measles. The disease shows itself also in close 
relation to tuberculosis. It has long been noticed that tuberculosis 
often follows close upon the heels of whooping cough. It is impos- 
sible to say in a given case whether the whooping cough made the 
soil fertile or merely aroused the latent disease. 

It is an error to consider whooping cough as a trivial malady. 
There occurred in England in one year, of 500,341 deaths, 10,318 
deaths from whooping cough. In New York in one decade, wherein 
4,062 deaths occurred from typhoid fever, there were 4,094 deaths 
from whooping cough. Hagenbach says that whooping cough had 
more victims in Basel in fifty years than any disease except typhoid 
fever and diphtheria. The general mortality is estimated at three 
to seven per cent. It has reached as high as forty-eight per cent 
in the second year of life. 

Symptoms. — The disease begins with the signs of an ordinary 
catarrh of the exposed mucous membranes. 

Whooping cough occurs, as stated, in paroxysms or explosions. 
It would appear as if the nerve centres suddenly discharged them- 
selves of accumulated irritation, as in a case of epilepsy. Close ob- 
servation of a case gives rise to the impression that the poison ac- 
cumulates gradually up to a certain point, when it may be no longer 
stored and is discharged with the explosion that characterizes a par- 
oxysm of the disease. 

Whooping cough is usually divided into three stages : the stage 
of catarrh, of spasm, and of resolution. The first stage lasts about 
one week. Sometimes this catarrhal stage is very short, and the spas- 
modic element manifests itself at the end of the second or third day. 
Very soon the cough assumes the convulsive character, and sooner 
or later occurs the typical staccato cough, with the long-drawn, aud- 
ible inspiration. The second stage has now set in. In these at- 
tacks the seizure is sudden. Sometimes, though not as a rule, there 
is a kind of premonition or aura which previous experience has 
taught the child to recognize. It is usually a sense of impending 
distress or danger, which leads it to leave its play and run to its 
parents, or grasp a chair for support. The aura may be in the form 
of a dyspnoea, a precordial distress, a nausea, sometimes an actual 
vomiting, whereupon ensues the series of expiratory coughs which 
distinguish the disease. The breath is lost. The face flushes or be- 
comes livid. The eyes protrude. Saliva flows from the mouth. 
The look is wild, bewildered. There is for a few moments the ap- 
pearance of imminent danger. 



WHOOPING COUGH. 115 

The discharge of the contents of the stomach and a mass of glassy, 
'glutinous mucus from the throat closes the attack. But the scene 
may be repeated once or twice before the last spasm yields. Inspi- 
ration then becomes quieter, and the child, pale, covered with sweat, 
exhausted, sometimes almost in collapse, is released until the next 
attack. Meanwhile it recovers itself entirely, resumes its play, un- 
mindful of the disease, until it is suddenly seized again. 

Paroxysms occur in every grade of severity. They are some- 
times so mild as to make the diagnosis difficult; in other cases so se- 
vere as to lead to rupture of vessels. Haemorrhages may occur from 
the nose and mouth. Subconjunctival haemorrhage is not uncommon. 
The membrana tympani ruptures at times, and free blood appears at 
the external meatus. Ectatic vessels burst in the skin in the face, in 
"the cheeks, to show, visible at a distance, subcutaneous extravasated 
blood. Haemorrhage from the stomach or intestine, or from the kid- 
neys or bladder, is much more rare. Haemorrhage in the brain, which 
sometimes occurs, is fortunately very much more rare. Hernia is 
not uncommon. Convulsions are possible. The duration of an at- 
tack is usually from a half to two minutes, though it seems to anxious, 
sympathetic relatives four or five times as long. 

As the severity stands in quite close relation with the frequency 
of attacks, it is important that the number be counted, as by a stroke 
on a piece of paper or a slate, according to the suggestion of Trous- 
seau. Diminution in the number of attacks is the first sign of 
approaching relief. Burman attributes the frequency of attack at 
night to the diminished vigilance of the respiratory centres, retarded 
and more superficial respiration, and greater accumulation of car- 
bonic acid gas. 

About the fourth decade of the present century attention began 
to be directed to the more or less constant appearance of an ulcer on 
the framum linguae, due to friction of the protruded tongue against 
the inferior incisors. It is absent altogether where the attacks are 
very light, or where the fraenum is short, or the tongue may not be 
protruded, or where the incisors are dull. It has been seen also 
independently of whooping cough, in cases of cough from ordinary 
catarrh, where the lower teeth have been unusually incisive. 

The spasmodic stage lasts, as a rule, two to four weeks, when the 
interval between the paroxysms becomes gradually longer and the 
explosions themselves less severe. 

Whooping cough is liable to many complications, especially on 
the part of the respiratory organs. Bronchitis belongs to the disease, 
and usually drowns all other sounds in the lungs with its rales. 
Any disease attended with bronchitis is liable also to broncho-pneu- 
monia, and broncho-pneumonia is the most frequent of the serious 



116 WHOOPING COUGH. 

complications of whooping cough. The spasmodic closure of the 
glottis and the powerful efforts of the expiratory muscles sometimes 
develop oedema of the glottis, more frequently emphysema of the 
lungs. The wonder is that emphysema is not more universal. The 
occurrence of it is, in fact, an exception. It is usually slight, mar- 
ginal or peripheral, and is marked by dilatation only of the air cells, 
whose walls are so resilient as to recover themselves entirely with 
the relief of the strain on cessation of the disease. Sometimes, how- 
ever, especially in cases of failing nutrition, tuberculosis, syphilis,, 
and rickets, the dividing walls are broken and air cells are ruptured. 
Still more rarely air may escape into the pleural sac to constitute a 
^pneumothorax, or break the lung at its hilus, reach the mediastinum,. 
or escape into the subcutaneous connective tissue and inflate, literally 
blow up, the upper half of the body. There is no better proof of the 
strength of the heart than the fact that it escapes damage under the 
spasm and stasis of whooping cough. 

Complications on the part of the nervous system are very rare. 
At the height of the attack there is experienced extreme anxiety, a 
sense of suffocation, a vertiginous bewilderment, approaching loss of 
consciousness, which disappears entirely with the recovery of the 
breath. The momentary apncea may be prolonged to the point of 
danger, and very young children may actually succumb to suffoca- 
tion. Vomiting, which is usually hailed with pleasure as indicating 
the end of the attack, may be excessive. It may continue into the 
interval. It may even produce collapse, or in more protracted form 
lead to marasmus. More frequently a more or less decided convul- 
sion ensues, and the case may be marked by a series of convulsions,. 
any one of which may prove fatal. Sometimes cerebral symptoms 
continue during the interval, and the case may bear the aspect of a 
meningitis. Stupor, coma, and hemiplegia would indicate the occur- 
rence of cerebral haemorrhage. 

Diagnosis. — The recognition of whooping cough in the convul- 
sive stage is an easy matter. The series of rapid, sudden, explo- 
sive, breath-taking coughs, attended by the evidence of venous stasis,. 
cyanosis (whence the old name blue cough), which ceases only when 
a quantity of mucus, under the combined efforts of cough, retching, 
and vomiting, is expelled ; the prolonged expiratory efforts, followed 
by a long-drawn, audible inspiration, which has been not inaptly- 
likened to the bray of an ass; and the gradual cessation of the dis- 
ease, sufficiently characterize it. 

The prognosis is for the most part entirely favorable.. Notwith- 
standing the threatened suffocation and tremendous strain upon the 
heart, recovery is the rule, and that without a trace of lesion. But 
complications and bad surroundings may intensely exaggerate the 



WHOOPING COUGH. 117 

natural benign prognosis. The prognosis is determined to consider- 
able extent by the age and sex. The disease is, as stated, from some 
inexplicable cause, not only more frequent but more severe in the 
female sex. It becomes less and less grave with advancing life. 
Majer declares that ninety-seven per cent of all the fatal cases occur 
under the age of five ; fifty-eight per cent in the first year. Biermer 
made a grand average of the established mortality rate, based upon 
the statistics of many authors, at 7. 6 per cent, a figure that certainly 
entitles the disease to respect. The most frequent causes of death 
are: 1, suffocation from spasm of the glottis; 2, broncho-pneumonia; 
3, haemorrhage; 1, marasmus. 

The prognosis is grave where the attacks reach fifty in the course 
•of twenty-four hours; at sixty it assumes special gravity. Individual 
attacks may do damage also by their intensit}"; thus haemorrhage 
may be copious from mucous surfaces. Blindness occurs occasionally, 
probably from oedema of -the brain. 

Prophylaxis. — As the disease has, at least at times, such grav- 
ity, prophylaxis assumes importance. The only prophylaxis worthy 
of the name is isolation. The patient must be separated, not only 
from children, but from adults who come in contact with unaf- 
fected members of the family. As this isolation, in a disease which 
is usually considered so mild, is practically impossible, attention 
should be directed rather to the protection of delicate members of 
the family ; they should be isolated. It is advisable that tuber- 
culous, rachitic, syphilitic, or otherwise diseased or debilitated chil- 
dren should be removed from the house as early as possible. 

The most essential element in prophylaxis at all times is the de- 
struction of the sputum. Though the individual is attacked with 
the suddenness of an explosion, mucus, at least in quantities, is not 
■expelled until the attack has spent itself, so that there is, for the 
most part, time for the collection of sputum in water. As in tuber- 
culosis, the handkerchief should never be used for the reception of 
sputum. 

Treatment, — The older writers used the anodynes early. Opium, 
in some form or other, was the shield which was soon interposed. 
In more modern times the active principle of opium, morphia, was, 
and is still, extensively employed. With the morphia are often 
combined five- to ten-grain doses of the bromide of sodium or potas- 
sium, or there may be added the hydrochlorate of apomorphia. The 
remedies commonly employed in the treatment of bronchitis are also 
frequently resorted to. The syrup, simple or compound, of ipecac, 
one-half to one teaspoonful ; the wine of ipecac in half these doses ; 
minute doses of antimony, one- sixty-fourth to one-thirty-second of a 
grain ; belladonna, one drop of the tincture for each year of life ; 



118 INFLUENZA. 

or atropine, one grain to one ounce of water, given in doses of front 
one to two drops two or three times a day. The iodide of potassium 
is a remedy of value. It may be given as follows : 

5 Potassii iodidi § ss. 

Aqua3 menthse piperita fl. § ss. 

M. Sig. Two to five drops in a dessertspoonful of milk three or four times a day. 

Excessive vomiting may be relieved by chloral, gr. ii.-v. Mild cases 
are best let alone. Bad cases call for control by opium. Change of 
climate is the only remedy which does really sometimes "act like 
magic." 

^ INFLUENZA. 

Influenza; la grippe; the grip. — An acute infection caused by 
a specific bacillus and characterized by catarrhal, gastric, and nerv- 
ous signs. 

Influenza has the same origin as catarrh, rheumatism, etc. — dis- 
eases derived from the Greek word meaning a flow or flux — but 
differs from these diseases in the fact that its origin came not from 
within but from without. It was derived, in the most ancient 
times, from extraneous influence. It was the "influence" of the 
stars or of the weather, mysterious telluric influence, that constituted 
influenza — an Italian word. 

Influenza takes the front rank among the acute infections on ac- 
count of its extent. It surpasses all other diseases in its range, in 
that it often covers the entire globe. It is the type of the pandemic 
diseases. It never attacks solely individuals, but always communi- 
ties, peoples, hemispheres. 

History. — Accounts of it date from the earliest times, and when 
first seen its universal distribution was appreciated. It was cer- 
tainly recognized as early as 1173 in Italy, Germany, and England. 
It prevailed as a true pandemic from 1510 on, at different periods,, 
with intervals ranging from forty to one hundred years. It showed 
itself in our own country first in 1627 in Massachusetts and Con- 
necticut, and extended to the West Indies and South America as far 
as Chili, and it reappeared again and again with us, at varying inter- 
vals of five to fifty years, without any distinct periodicity, up to the 
present time. It is established of influenza, in a general way, that 
it originates in the East and extends over the "West. Thus the most 
recent epidemic that has visited our country was first recognized in 
Bokhara in May, 1890. It reached St. Petersburg in October, Ber- 
lin in November, London in December, and by the middle of Decem- 
ber showed itself in individual cases in Philadelphia and New York r 
whence it gradually extended over the United States, to appear in 
Mexico in the following spring. 



INFLUENZA. 119 

Etiology. — The first cases of influenza are usually unrecognized. 
The individuals affected are said to be attacked with a bad cold, or 
nervous phenomena are interpreted as signs of other diseases, typhoid 
fever, etc. It is only when individual cases multiply that the poison 
accumulates to sufficient extent to strike the masses, and this fact has 
led to the belief in the sudden appearance of epidemics. Influenza 
is spread hj human intercourse. It follows the line of travel, and 
extends with the transportation of individuals by river and rail, with 
the velocity in our clay that corresponds to the rapidity of modern 
transit. Having traversed a country and gone beyond it, it is liable 
to return and reappear, especially among individuals previously 
spared, and thus the disease hovers about a country for a period of 
months, sometimes years, before it entirely disappears. 

The cause is in the air. Crews of ships have been seized in 
the open sea. The fleet under Admiral Kempenfeld had to put into 
harbor in the second week at sea, having had in the meantime no 
connection with, the land; and this observation has been repeatedly 
made. Hermits are said to have been attacked in the woods, or in 
the caves of their isolated homes. 

Influenza travels against the wind as well as with it, and is 
totally independent of climate, season, or soil. It is difficult to fix 
the place amongst the acute infections where influenza belongs. 
Whether it shall be considered a miasmatic or a contagious disease 
will depend altogether upon what is meant by these terms. Advo- 
cates of miasm contend that the disease originates de novo, or that it 
is carried by the wind, and meet the objection that it is often carried 
against the wind by the assumption that the wind at greater altitudes 
moves in a different direction. We are, however, little concerned 
with the direction of the upper strata of the air. The wind at high 
altitudes is more liable to blow down the castles we build in the air 
than to affect the habitations in which we live. 

It is observed of influenza that it shows itself first along the lines 
of river and rail, and that it appears first in towns about railroad sta- 
tions, later in places removed from the lines of travel. Pfeiffer (1892) 
discovered the micro-organisms of influenza as bacilli in the pus cells 
of tracheal mucus. They are minute structures, about the breadth 
and half the length of the bacilli of mouse septicaemia. They are best 
displayed with the dilute Ziehl or in the hot Loffler methylene solu- 
tion. They are immobile in hanging drops. The bacilli of influ- 
enza form colonies on one and a half per cent sugar agar, visible 
only with a lens, in drops as clear as water. An absolutely dis- 
tinctive feature, according to Kitasato, is the fact that these drops 
ahvays remain apart; they never coalesce. The bacilli penetrate 
the peribronchial tissue to reach the surface of the pleura. Canon, in 



120 INFLUENZA. 

the same year, demonstrated the bacillus in the blood itself. Toxines 
from these micro-organisms develop the complications and sequelae — 
endocarditis, nephritis, etc. — of the disease. 

No period of life is exempt, though infancy is comparatively rarely 
attacked. The greatest liability ranges from twenty to thirty. The 
period of danger is in advanced life. The incubation is short, Wo 
to three days. In most cases the onset is sudden. 

Symptoms. — Prodromata, when they exist in the exceptional cases, 
consist of malaise, languor, headache, light catarrh. The disease sets 
in, as a rule, suddenly — a fact of value in a diagnostic way— and dis- 
tinguishes itself in its course by three sets of symptoms, to wit, the 
catarrhal, gastric, and nervous. Epidemics vary greatly with re- 
ference to the intensity or predominance of individual symptoms. 
Individual cases vary in still greater degree. It is, however, the co- 
incidence of symptoms on the part of these various organs which estab- 
lishes the nature of influenza and distinguishes it from other -catar- 
rhal affections. The catarrhal symptoms may affect any part of the 
respiratory tract; i.e., there may be cor yza, irritation, burning, dry- 
ness, or discharge from the nose, sneezing, hyperesthesia of the 
conjunctiva, photophobia, or catarrhal affection of the throat which 
may not be distinguished from a simple angina. There is much 
more commonly catarrh of the bronchial mucous membrane. The 
bronchitis of influenza distinguishes itself by its universality. It 
is a bilateral affection. It shows great disposition to extend to and 
involve the capillary bronchi, whence the liability to, and danger 
of, catarrhal pneumonia. There is corresponding oppression about 
the chest, difficulty of breathing, precordial anxiety. 

The gastric symptoms are more marked in childhood. The disease 
is often announced in children by vomiting, and cases have been 
reported in which the severity of the vomiting has excited the suspi- 
cion of the development of scarlet fever, cerebro-spinal meningitis, or 
pneumonia. As a rule, however, gastric symptoms are marked' 
rather by anorexia, sometimes nausea, dyspepsia, more especially 
duodenal catarrh with a light icterus manifest in the tint of the 
conjunctiva. Exceptional cases show diarrhoea, or even bloody dis- 
charges. 

It is the third set of symptoms — the nervous symptoms — which 
more especially distinguish influenza from other catarrhal affections 
and give it its specific place as distinct from common catarrh. 
There is headache, some of which may be accounted for by catarrh 
in the frontal sinuses, most of which, however, is toxic. There is 
supra-orbital neuralgia. The headache is frontal, more rarely oc- 
cipital. Neuralgic pains wander about the body. Patients com- 
plain especially, often bitterly, of deep-seated muscle and bone 



INFLUENZA. 121 

jjains. There is with these pains great depression of spirits, 
something more than the mere hebetude of the inception of typhoid 
fever. These sinking sensations, which take the interest out of 
and create a disgust for life, characterize well-marked cases of in- 
fluenza. In exceptional cases nervous symptoms of graver charac- 
ter occur. The disease may be announced in a child in epileptiform 
convulsions. Various paralyses, chorea, tetanus, psychoses have 
been noticed in different cases. A patient may be affected with in- 
somnia for a week. Roger reported the case of a lady who slept 
for over a week. Da Costa mentioned the case of a woman, of great 
delicacy and refinement, who greeted the appearance of the physician 
with blasphemy. 

Influenza calls out latent diseases. This is especially true of tu- 
berculosis. Many cases date the origin of their various diseases to 
an attack of grippe. " I was all right until I had the grippe, " is a 
common observation : and while it is possible here to confound with 
influenza the symptoms of individual diseases, as of tuberculosis or 
pneumonia, it remains true that influenza is a common exciting 
cause of these affections. 

Diagnosis.— The three sets of symptoms — catarrhal, gastric, 
nervous — distinguish the disease. Influenza is overlooked or misin- 
terpreted only in the beginning of an epidemic when the cases are 
few. The predominance of nervous distress, more especially nervous 
depression and dejection, is a characteristic feature of the disease. 

Prophylaxis. — According to observations Goldschmidt. of Ma- 
deira, made in the presence of both diseases as epidemics, revaccina- 
tion with vaccine virus protects not only against variola, but also 
against influenza. This statement needs verification. 

The prognosis of influenza itself is good ; the mortality is almost 
nil, but the fraction of one per cent — Lynrote says 0.25. Lee reports 
1,120,000 cases in Pennsylvania in the last epidemic, with 7,780 
deaths, or 1 in li'2 cases. Nevertheless, the occurrence of influenza 
is a serious thing. It calls out, as has been stated, latent diseases. It 
aggravates the progress of all diseases in course and terminates 
many fatally. The disease assumes special gravity in age. It is 
difficult for an aged person to escape an attack of influenza with 
good health. It is the indirect cause of death in many of these 
cases — indirect through catarrhal pneumonia or heart failure. So 
the death list is duplicated through the prevalence of pneumonia ; 
and while it is true that the mortality fist at the end of the year is 
not sensibly increased by the occurrence of an epidemic of influenza, 
it makes a great difference in a community whether these deaths be 
diluted through a period of months or years or be concentrated upon 
a few weeks. 



122 HAY FEVER. 

The treatment is now nearly specific. To meet individual symp- 
toms and sustain the patient for three to five days constitutes the 
rational therapy of influenza. A most essential factor is rest. All 
patients affected with influenza should observe quiet and repose of 
mind and body in a properly ventilated and warm room. 

Fever seldom calls for treatment. The temperature rarely rises- 
above 101° or 102°, and when excessive is best met by sponge baths. 

The pain is best relieved by broken doses of Dover's powder, or, 
in the presence of much nausea, by phenacetin. Phenacetin may be 
given in a single dose of ten grains to an adult to secure a peaceful 
sleep. Caution must be entered against the abuse of any antipy- 
retic. Where there is much debility from age or heart weakness, 
quinine may take its place. The salicylates have something of a 
specific influence in relief of the symptoms of influenza. Choice 
may be had as between salicin, salol, and salicylate of soda. All 
these agents, however, have a sensible though slight effect in de- 
pressing the circulation, and should be administered in conjunction 
with a stimulant, a glass of wine or a dessertspoonful or tablespoon- 
f ul of whiskey. A good salicylate in the treatment of influenza is 
the salicylate of cinchonidia. Support of the Peruvian bark principle 
counteracts the depression of the salicylic acid. It is bitter and in- 
soluble, and hence should be given in capsule or pill in dose of two 
to five grains every two to four hours. The best single remedy is 
salipyrin, which may be given in powder or wafer in the dose of 
grs. x.-xv. every two to four hours. Salipyrin is almost a specific 
in the treatment of influenza. During the attack all patients should 
remain at home at rest, and in convalescence should expose them- 
selves with caution. 

HAY FEVER. 

Hay fever ; hay asthma ; catarrhus cestivus, summer catarrh ; 
June cold. — Catarrh of the mucous membrane of the eyes and air 
passages, produced only in sensitive subjects, by pollen, hence periodic 
in recurrence and protracted in duration. 

History. — The disease is modern not only in recognition, but actu- 
ally in origin. It was first announced by Bostock (1819) asa" period- 
ical affection of the eyes and chest," based on personal experience. 
Elliot son (1839) pointed to pollen as the probable cause of the disease. 
Helmholtz, also a sufferer, ascribed it to vibrios and lauded quinine 
by insufflation in its relief. Blackley (1873), another victim, proved 
pollen to be the true materies morbi. Beard (1876) laid stress upon 
the neurotic temperament which constitutes the susceptibility to the 
disease. The condition of the nasal passages themselves, as consti- 
tuting susceptibility, is a contribution of the last decade. 



HAY FEVER. 123 

Etiology. — Hay fever is a rare disease. It demands a peculiar 
susceptibility or idiosyncrasy, as, of the millions exposed, but very 
few are attacked. It is almost confined to the Anglo-Saxon race, 
and follows it in foreign lands, as in Asia and Africa, where the dis- 
ease is unknown to the natives. It spares foreigners for the most 
part in England and America. It shows predilection for males in 
the ratio of 2:1, probably because of their greater out-door ex- 
posure. It shows preference also for the upper classes, especially 
for the clerical avocations. It attacks maturity up to forty, only 
very exceptionally youth or age. The liability is transmitted by 
heredity ; and whether inherited or acquired, once developed the 
disease recurs with great regularity or periodicity about the same 
time every year. Certain cases have anatomical foundation in the 
condition of the nose, in occlusions, hypertrophies, polypi, sensitive 
areas, etc. 

Pollen is the chief if not the only cause. Blackley proved by ex- 
perimentation upon himself and others that the disease was caused 
by pollen, aggravated by greater exposure and limited by less, as by 
active movements out-doors or quiet within. The pollen of many 
plants will produce it. That of the graminacese causes ninety-five 
per cent of cases. Wyman ascribed most of the cases in America to 
the wormwood, which blooms in August and September. The pollen 
of plants in blossom often fills the air, is wafted at times to great 
distances, many miles, to be deposited, sometimes visibly, on roads 
and streets, where it may appear like sulphur. 

Symptoms. — Hay fever begins, as a rule, suddenly, at or about 
the day it is due — wherein it may be helped by a lively imagination — 
as a coryza or an asthma. The disease shows itself in two forms, ca- 
tarrhal 'and asthmatic. These forms may follow each other or co- 
exist. In the catarrhal form there is coryza. The conjunctivae are 
inflamed, the eyes burn, and hot tears run over upon the face. 
There is photophobia and headache. The nose itches and burns. 
There is sneezing, sometimes violent and persistent. The whole 
tract of the nose is blocked by cedematous swelling, often of rapid 
onset, of the entire mucosa, The voice is nasal. The inflammation 
extends to the throat, which is also red and dry, with sensations of 
rawness and actual pain. 

In the asthmatic form there is sudden, oppressive, and persistent 
dyspnoea. Wheezing sounds pervade the entire chest. With this 
distress there is the depression of spirits and disinclination or ac- 
tual incapacity for effort which belongs to true asthma. 

The diagnosis depends upon the recurrence — periodic — in sum- 
mer, and persistence throughout the exposure. 

The pjrognosis is good, quoad vitam ; bad, quoad valetudinem. 



124 PNEUMONIA. 

The disease subsides to leave no trace, but recurs every year and 
lasts for weeks or months. 

The treatment is addressed to the temperament or tendency, with 
the administration of, especially, arsenic, which, in the form of the 
liquor potassse arsenitis, is given in doses of gtt. ii.-v. ter in die to 
tolerance. The remedy should be begun before the attack. Qui- 
nine ranks next in dose of gr. v. twice a day, morning and eve- 
ning. During the attack some relief may be obtained with solutions 
of cocaine, four to ten per cent, applied with a brush or by insuffla- 
tion. Unfortunately such relief is too temporary to be of much 
value. The insufflation of an ointment of boric acid and vaseline, 
* gr. xv. to 3 ss. , soothes the irritated nasal membrane. Intense 
conjunctivitis may be relieved by the instillation of a solution 
of cocaine, four per cent, or of morphia gr. iv. to aqua destillata 
§ ss. Gargles of potassii chloras, or internal exhibition of the 
solutio saturata, 3 i. every two hours, help the throat. Chloral 
in small doses, gr. v., may relieve the asthma. It is common 
practice to administer the iodides in this as in other asthmas, 
being careful to avoid iodism. Belladonna generally does more harm 
than good. Morphine in small dose, gr ^ - -g-, is sometimes indis- 
pensable. Phenacetin or the salicylates relieve the headache and 
the fever. Patients should stay in-doors and keep quiet. The only 
radical relief is change of climate — i.e., sojourn in some place dis- 
tant from the cause, as at the White Mountains, Fire Island, etc. 
But individual cases yield to surgical treatment, the application of 
the galvano-cautery, chromic acid, trichloracetic acid, etc., after 
cocaine. 

PNEUMONIA. 

Pneumonia (nvsviiovia, nvev jj.gov ? the lungs) ; fibrinous, lobar, 
genuine pneumonia. — An ubiquitous, non-contagious, acute, general 
infection, with its main local expression in the lungs ; caused by a dip- 
lococcus ; characterized by high fever, pain in the side, cough with 
expectoration of a glutinous, rusty-colored sputum, consolidation of 
the lungs with coagulated blood, and resolution in five to nine days 
with restitutio ad integrum. 

History. — Pneumonia was known as such and as peripneumonia 
by Hippocrates, though not separably, in antiquity, from pleurisy and 
other painful affections of the lungs. Even Sydenham (1670) failed 
to distinguish between pneumonia and pleurisy. The gross anatomy 
was first described by Morgagni (1761). Pneumonia was separated 
into the three well-known stages, congestion, hepatization, and sup- 
puration or resolution, by Laennec (1819), by whom the disease was 
first recognized in life ; the lesion (croupous exudation) was first 



PNEUMONIA. 125 

accurately described by Rokitansky (1841) ; the physical signs and 
diagnosis were definitely established by his contemporary and col- 
league, Skoda. Acute croupous or fibrinous is so-called from its 
exudation ; lobar, from its extent ; genuine, in distinction from catar- 
rhal, hypostatic, metastatic, etc., forms of pneumonia. 

Etiology. — Pneumonia, in all time limited as a local disease, 
"the type of the acute inflammations," was finally evolved as an 
acute, general infection, with main local expression in the lungs, by 
Jurgensen (1872); a pathogenic micro-organism discovered by Fried- 
lander (1883), and more conclusively demonstrated by A. Frankel 
(1886). The frequency of pneumonia is evidenced by the fact that it 
constitutes three per cent of all diseases and six per cent of all internal 
diseases ; its gravity by the fact that it causes 6.G per cent of the 
total mortality and 12.7 of the mortality of internal diseases, ranking 
thus in frequency and gravity next to tuberculosis. The disease 
occurs at all ages — three-fifths of the cases before the age of fifteen ; 
and at all seasons — two-thirds of cases in spring and winter (minimum, 
September to November), with predilection for feeble constitutions 
and in-door life. Sinking subsoil water releases soil bacteria ; rain- 
fall by precipitation frees the air. The history of seven hundred and 
fifty cases examined by Diet! showed previous perfect health in but 
eighteen per cent. Contrary to common belief, pneumonia is not 
contracted by trauma or by taking cold. Trauma may produce an 
inflammation of the lungs, but not a croupous pneumonia. Under 
trauma are included inhalations of dust. Thus the percentage of 
cases among coal merchants not especially exposed to dust is 14.4; 
among coal miners, working in almost suffocating dust, but 4.7. Ex- 
cessive use or straining of the lungs, as in playing wind instruments, 
crying vocations, etc., do not predispose to attack. Regarding 
' ' cold " it may be said that over eighty per cent of individuals at- 
tacked can recall no exposure in explanation of the origin of the dis- 
ease. Soldiers are attacked in garrison life, seldom during field 
service ; sailors ashore or when near the coast, seldom upon the 
open sea. Deaths from pneumonia among the nuns of Paris 
amounted to 7.02 per one thousand; among washerwomen, 3.05. 
Among six hundred and seventy laborers constantly exposed to cold 
and wet, engaged in loading vessels, Parent-du-Chatelet found but 
one case of " congestion of the lungs " Prisoners and factory girls 
furnish a large contingent of cases. The ratio of deaths among deni- 
zens of cities and the country is as 5 : 2. Cold and trauma may, how- 
ever, act exceptionally as exciting or localizing causes in cases where 
the real cause pre-exists in the body, just as injuries to the skull and 
spine may localize abscess of the brain and caries of the spine, or 
measles excite tuberculosis. 



126 



PNEUMONIA. 



f 






Fig. 89.— Pneumococcus 
of Friedlander; oval cells 
with gelatinous envelope. 



It was the recognition of these facts, together with the observations 
that the disease (1) has different temporal and spatial relations from 
affections commonly ascribed to taking cold ; (2) that other organs 
besides the lungs — notably the heart, brain, kid- 
neys, and spleen — are often also involved ; (3) 
that the general symptoms, fever, prostration, 
gastro-intestinal signs, etc., do not, by any 
means, of necessity correspond with the extent 
of invasion of the lungs, which should be the 
case in a local disease (i.e., slight invasion of ten 
shows grave symptoms, and vice versa) ; fin- 
ally, (4) that the disease runs a specific course, 
terminating at a definite period, after the manner of most of the acute 
infections — which led Jurgensen, a close, keen, and critical observer, 
to anticipate the disclosures by the bacteriologists 
of the real cause of the disease in certain definite 
micro-organisms. 

Bacteriology. — Of the various micro-organisms 
found in pneumonia, two have been finally elimi- 
nated as pathogenic — viz., the pneumococcus of 
Friedlander and the diplococcus of Frankel. Fried- 
lander and Frobenius described as " pneumococcus " 
certain micro-organisms discovered in sections of 
hepatized lung tissue, in the alveolar exudation, and 
later in the rusty sputum. These micro-organisms 
could be cultivated and inoculated to produce the 
disease. 

Inspected in hanging drops they are seen to be 
thicker in one diameter, hence to constitute really 
very short bacilli. As found in the body they are 
enveloped in a distinct capsule which encloses, as 
a rule, but one, exceptionally two or more elements. 
They belong to the class of facultative anaerobes ; 
thrive, hence, without oxygen. They are motion- 
less. In staining, the capsule remains uncolored. 
They do not fluidify gelatin, and develop in the test 
tube in the form of a nail with a thick head. 
They thrive upon agar and luxuriate upon the 
potato. They are found in but 5.5 per cent of 
cases. 

It is now established that the true pathogenic micro-organism of 
pneumonia, found almost universally in typical cases — ninety-two per 
■ cent of cases (Weichselbaum) — is the " diplococcus " of Frankel (first 
. seen and described by Sternberg), which is closely allied to the pneu- 




Fig. 90. — Pneumo- 
coccus of Friedlander; 
stick culture in gela- 
tin, nail shape. 



PNEUMONIA. 



127 



'• - 



mococcus of Fried! ander. This coccus is also, strictly speaking, a ba- 
cillus, with one end pointed — " lancet-shaped " (see Frontispiece, Fig. 
6). It is found in pairs, whence the name; sometimes in rows or beads 
of five or six or more elements ; is also encapsulated in the body, but 
never out of it as in cultures. It differs from the pneumococcus in 
admitting of double coloration, and in not being decolorized by Gram's 
method. It grows with difficulty upon gelatin, thrives upon agar 
and in bouillon. Injected into the blood of rabbits and guinea- 
pigs, it produces septicaemia, which is fatal in twenty-four to forty- 
eight hours. Introduced directly into the lungs of rabbits, mice, 
guinea-pigs, and dogs, it produces intense inflammation of the pleura 
with condensation of the lung tissue, identical with the lobar pneu- 
monia of man. A peculiarity of this micro-organism is the rapidity 
with which it loses its virulence in four to five days. Successive 
cultivations with every precaution show loss of infecting properties, 
which can be maintained .only by return to 
the animal body every ten days. Heat at- 
tenuates and finally abstracts the infectious 
principle, and thus the diplococcus becomes 
attenuated in a few days at 41° C. and in- 
nocuous in twenty-four hours at 42° C. 
These diplococci have been found in the 
dust of the floors of houses, as also in the 
saliva of healthy individuals, as have, how- 
ever, other pathogenic micro-organisms, 
Staphylococcus aureus, actinomyces, etc. 

The avenue of entrance into the body is not definitely estab- 
lished. It has wide distribution in the body : throat, ear, meninges, 
joints, kidneys, pleura, peritoneum, etc. Inhalation experiments do 
not furnish uniform results. Entering the lungs, it excites in these 
organs specific inflammation, attended by hyperemia and hepatiza- 
tion, to be followed by fatty and mucous degeneration and the stage 
of resolution. From the lungs or other portal it enters the blood, 
in which it has been occasionally detected, to lodge by preference, 
in individual cases, in the spleen, kidneys, endocardium, and 
membranes of the brain, etc. Whether the inflammation in these 
organs depends in all cases upon the diplococcus of pneumonia or 
upon other secondary invasions, as of streptococci, staphylococci, 
etc. , remains as yet undetermined. The differentiation of the diplo- 
coccus from the pathogenic streptococcus is often very difficult. 

The short duration of the disease corresponds with the short life 
or infectiousness of the diplococci. They evolve products, antitox- 
ines, fatal to their growth. Phagocytic processes not yet dem- 
onstrated of these micro-organisms do not need to be invoked to 




® ® & 

Fig. 91.— Diplococcus pneumo- 
niae (Frankel-Weichselbaum) : a, 
lancet shape ; 6, in gelatinous 
envelope; c, d, in rows and beads. 



128 



PNEUMONIA. 



account for the duration or the recovery from the disease. Irregular, 
secondary, and complicated cases of pneumonia may be produced 
or explained by invasion of other bacteria, as by the streptococcus, 
staphylococcus, other diplococcus, typhoid bacillus, etc., all of which 
may undoubtedly produce inflammation of the lungs. 

Symptoms. — Pneumonia begins, as a rule, suddenly, without pre- 
monition or prodromata, which may, however, occur in less than 
one-fourth of cases. Thus malaise, wandering pains, and distur- 
bance of digestion may precede an attack of the disease one or two 
days. Pneumonia is generally announced by a violent chill, often 
at night, the severity of which is equalled only by a sharp attack of 
* malaria or small- pox. The chill is especially pronounced in adoles- 
cence or adult life. In infants the onset is marked by coldness of 



^® Av ■■■■:■■$ ^ ':'. '/£, .;^>J>WW ^ . 




m 






i^ 



« 






Fig. 92. Fig. 93. 

Fig. 92.— Diplo cocci from sputum, acute pneumonia, early stage: a, pus cells, c, diplococci 
with capsules (Woodhead and Hare). 

Fig. 93.— Diplococcus of pneumonia in sputum, much more highly magnified. 



the surface, vomiting, convulsions, or even coma ; in the aged and 
cachectic the onset of the disease is much more insidious. 

Fever rises rapidly, reaching its greatest elevation about the 
third day. The chill and fever are accompanied or quickly followed 
by sharp pain in the side, due to accompanying pleurisy, for lung 
tissue itself is not sensitive to pain. Pain is, as a rule, wanting in 
old people, in whom the disease usually begins more centrally, to ex- 
tend outward much more gradually. By the second day the fever 
is high, especially in young patients. In children it not infrequently 
reaches 105°. In adults 104° represents an average case. The tem- 
perature is often out of all proportion to the amount of invasion of 
the lung. It may stand at 105° when the lesion of the lung may be 
difficult to fix, or may scarcely show itself until the half or whole of 



PNEUMONIA. 



129 



the lung is blocked with blood. After the third day the fever 
begins to show daily remissions, and by the fifth to the seventh day 
it falls suddenly, especially in the young, reaching the normal degree 
within thirty-six hours — i.e., by crisis. The "crises" (upivco, to 
decide) of the older writers were mostly based upon studies of fever 
in pneumonia. In the majority of cases, however, fever ends rather 
by a rapid lysis {Xvsiv, to dissolve). Fluctuations occur throughout 
the disease. Such uniform or sustained elevations as are charac- 
teristic of typhoid fever are unknown in pneumonia. Crisis is pre- 
ceded or caused by leukocytosis, which liberates antitoxines. The 
ratio of white to red corpuscles may be at this time 1 : 60 or 1 : -10 — 
a valuable prognostic point. The fall of temperature, with general 




Fig. 91. Fig. 95. 

perature chart; fibrinous pneumonia; adult; crisis on sixth day. 

^mperature chart; fibrinous pneumonia in child; pseudo-crisis on seventh, real 
y (Eichhorst). 



of symptoms and resolution of the disease, occurs in 

3 per cent of cases before the seventh day, in seventy- 

>er cent before the ninth day. In advanced age, or cachexia 

l; age, the fever frequently runs quite a different course, 

ascent and decline being much more gradual and the course 

u ,vr "ted. The typical curve is also altered by complica- 

rapid rise of temperature at the start distinguishes a 

ty> neumonia from a typical typhoid fever. 

Cough commences within the first two days, often with the pain. 
It is due either to associate bronchitis or pleuritis, usually to both. 
Since some degree of bronchitis is always present, expectoration 
consists at first of frothy mucus, to assume later a more significant 



130 PNEUMONIA. 

appearance. The sputum becomes thick, viscid, tenacious, adher- 
ing to the receptacle like glue, even when inverted. About the 
second or third day, in a large proportion of cases, it has imparted to 
it a peculiar rusty or brick-dust color, due to admixture of blood 
corpuscles. This color is not usually present in pneumonia in old 
age. Pure blood may show itself in streaks, or be itself the sole 
constituent of sputum. Liquid, black or dark "prune-juice spu- 
tum," often accompanied by fcetor due to mixed infection, is of 
grave import as indicating decomposition of the blood. Purulent 
sputum, which is more common, also proves mixed infection with 
pyogenic bacteria, but is not of necessity so grave. 

Respiration is soon increased to 30 to 40 per minute. It is hur- 
ried, shallow, superficial, and painful — painful because of pleu- 
risy. It is, as a rule, more rapid in children than in adults ; it may 
remain unaffected in age. The pulse, 100 to 120, full and bounding 
at first, becomes later soft and feeble. It is not increased in the 
same ratio with the respiration. Very early in the progress of 
the disease the pulse-respiration ratio is disturbed, respiration 
being hurried out of all proportion to the pulse. Thus the nor- 
mal ratio, two to nine, or one to four and a half, may become two 
to four, two to three, or even one to one. The majority of cases 
show temporary albuminuria, due to retarded circulation during 
the height of the disease. The chlorides diminish and may be 
entirely absent from the urine, as is readily shown by the nitrate of 
silver test. They reappear about or at the time of crisis. This sign 
has lost much of its former diagnostic and prognostic value since 
the observation that the same change occurs in the 
fevers. The presence or absence of chlorides is large 
refusal or lack of digestion of food. 

Herpes occurs in about fifty per cent of cases, The ve 
pear upon the face or exceptionally over the body, 
prognostic as well as diagnostic significance. It does 
in typhoid fever. In a large majority of cases in whi 
pneumonia in well-developed form it foretells recovery TV 
ance of herpes is more welcome because it shows itself o r 
about the third day of the disease. Unfortunately it I 
so often in age. 

Physical Signs. — Pneumonia picks by preference upon 
lung, the base rather than the apex. It is bilateral 
tional cases, and then more especially in drunkards. Pneumonia, <x\, 
the apex is often confounded with tuberculosis. Inspection shows 
limited expansion. The difference in the excursion of the two sides 
is best seen when viewed from behind. It is perhaps better appre- 
ciated by palpation than by inspection, the hands being placed flat 






PNEUMONIA. 



131 



upon the postero-lateral parts of the chest. Percussion may disclose 
an alteration of the note, even early in the stage of hyperemia. 
The sound may become tympanitic and thus deceptive. This sign is 
wont to recur after resolution, and may persist for several weeks. A 
little later, in a few hours to two or three days, percussion shows 
dulness over a sharply defined area. It may be observed only upon 
the posterior aspect of the chest. When doubt arises as to the char- 







I 





Fig. 95.— Section of alveolus of lung in croupous pneumonia, filled with exudate consisting of 
fibrin, with desquamated epithelium and red and white blood corpuscles. 



acter of the pneumonia, whether croupous or catarrhal, unilateral 
dulness speaks for croupous, bilateral for catarrhal pneumonia. 
Vocal fremitus and resonance are both increased. Auscultation 
furnishes the most valuable evidence in pneumonia, as it reveals 
something characteristic in the first as well as in the second stage of 
the disease. During the stage of hypersemia the bronchioles as well 
as the air cells become more moistened from exudation into their 



132 ' PNEUMONIA. 

interior, so that the act of inspiration separates them, and the pene- 
tration of air is attended with a fine crackling sound, the crepitant 
rale. This sound, which is often likened to that which is heard when 
salt is thrown on the fire, and is closely simulated by rubbing the 
hair between the fingers near the ears, is heard only at the end of 
full inspiration. Heard in this stage at this time, it is known as the 
crepitans indux. It is soon obliterated. The air cells and bronchi- 
oles are filled with blood, which coagulates to form a cast of their in- 
terior. The lung has become solidified. A piece of it exsected sinks 
in water. There is no longer question of the penetration of air be- 
yond the larger bronchial tubes. 

The second stage of the disease has now set in, and the natural 
vesicular rale, the crepitant rale, disappears entirely, to be substituted 
by bronchial respiration. Sometimes nothing is heard in the act of 
respiration. This silence is often more eloquent than sound, as indi- 
cating the effusion of fluid in the pleural sac. The crepitant rale is 
of value in establishing the nature of the disease, because it is heard 
at the base of the lungs, where other diseases which might produce 
it do not naturally exist. A crepitant rale may be heard also in 
tuberculosis, bronchitis, and is often closely simulated by the friction 
sound of pleurisy. The location of the sound under the clavicles in 
tuberculosis, everywhere over the chest in bronchitis, and in both 
cases with other associate sounds; the location of the sound in the re- 
gion of the nipple in pleurisy, helps to distinguish these affections. 
With the bronchial respiration there is often bronchophony , heard, 
as a rule, most distinctly about the angle of the scapula, or, in apex 
pneumonia, under the clavicle. After the absorption of blood in the 
process of resolution the crepitant sound returns. It is then heard 
in connection with both inspiration and expiration, and is known as 
the crepitans redux. It is now, as a rule, accompanied by coarse 
and fine mucous and submucous rales. 

Pneumonia resolves itself, as stated, in seventy-five per cent of 
cases, in from five to nine days. Most of the blood is absorbed, some 
of it is converted into mucus and expectorated. In certain cases the 
process of resolution does not occur. Suppuration takes place. The 
air cells and bronchial tubes are filled up. with pus. The disease is 
said to have passed into the stage of suppuration. This process of 
suppuration does not belong to pure pneumonia. It follows mixed or 
subsequent infection with the micro-organisms of pus. It occurs in 
connection with the pneumonias produced by these micro-organisms, 
by that of the typhoid bacillus, etc. This event may not be known • 
by any special change in the signs elicited by percussion and auscul- 
tation. It is recognized rather by general symptoms, by the prostra- 
tion, weakening of the pulse, chilly sensations, rise and fall of tern- 



PNEUMONIA. 133 

perature, resulting from pj^cemia ; sometimes by sweats, by the ap- 
pearance of pure pus in the sputum ; sometimes by the appearance 
of disorganized blood to constitute the ' ' prune- juice " sputum. 

The pleura is almost always involved. The disease is essentially 
a pleuro-pneumonia. Sometimes pleurisy predominates throughout 
the history of the disease. Not infrequently it overshadows the 
pneumonia during the first few days. Ordinarily it subsides, so that 
pleurisy with perceptible effusion is present in but five per cent of 
cases. 

As already stated, pneumonia is a general infection. Its chief 
local manifestation is in the lungs. It involves, however, other or- 
gans, in which it sometimes shows its main symptoms. In two hun- 
dred and thirty cases of pneumonia treated by Liebermeister in the 
hospital at Basel, occurred as complications : pleuritis with abun- 
dant exudation, forty-one times ; well-marked acute nephritis, but 
once ; diarrhoea, twenty-five times ; meningitis, probably on account 
of the prevailing epidemic of cerebro- spinal meningitis, twice ; peri- 
carditis, nine times ; endocarditis, twice ; icterus, sixty-five times ; 
decubitus, five times. 

The frequency with which the brain is affected is indicated in 
the old names, cerebral or meningeal pneumonia. Many cases are 
marked by nervous symptoms, especially in childhood and age. A 
temperature of 103° in childhood or 102° in old age is not uncom- 
monly attended with delirium. The micro-organisms of pneumonia 
show a predilection for the meninges of the brain. Victims of alco- 
holism attacked with pneumonia show brain symptoms, as a rule. 
Slight albuminuria is often found in pneumonia, as in any febrile 
disease, due to high temperature and blood stasis. In a certain pro- 
portion of cases true Bright's disease ensues. The spleen is enlarged 
in about one-half the cases. Sometimes the disease seems to spend 
its force upon the digestive system with all the signs of gastrointes- 
tinal catarrh. Icterus is a very frequent sign. 

Though pneumonia is of short duration, it is frequently attended 
with serious parenchymatous change. In all cases the chief danger 
is on the part of the heart. The interference with the circulation 
throws extra work upon the heart, since it must force the same 
amount of blood through a smaller amount of lung tissue. The 
heart is also directly damaged by the toxic products of the disease. 
It becomes thus incompetent to do the extra work thrown upon it. 
Heart failure results. The majority of deaths in pneumonia is due, 
not to high fever, nor to sepsis in its ordinary sense, nor to any of the 
previously mentioned complications, but to paralysis of the heart. 
The condition of the heart is, therefore, the index to the situation. 
Heart failure may be indicated by general prostration, increase in 



134 PNEUMONIA. 

the dyspnoea, cyanosis. Above all other signs, the pulse in pneumo- 
nia is to be closely and continuously watched throughout the course 
of the disease. An irregular, compressible, fluttering pulse, fading 
when the arm is elevated, is a sign of a flagging heart. Nine-tenths 
of the deaths from pneumonia are due to heart failure, which shows 
itself, in the majority of cases, by the fifth or sixth day of the disease. 
Every effort is, therefore, made to conserve the strength of the 
heart, and under no circumstances is a patient allowed to rise in or 
from the bed. The mere elevation of the body for the purpose of 
examination has proven fatal. Bad cases should be simply turned 
over in bed. 

Many forms of pneumonia were formerly described, based chiefly 
upon symptoms, not upon causes or lesions. True pneumonia runs 
a course so typical as to be explicable only by a uniform typical cause. 
But abortive, protracted, and irregular forms do undoubtedl}' occur, 
as do also rapid, migrating, asthenic, etc., forms. The pneumonia 
potatorum is a dangerous form. " Congestion of the lungs" is a 
common term for a pneumonia aborted in one or two days. After 
exudation there can be no abortion. Resolution, once begun, usually 
proceeds rapidly to completion, with restitutio ad integrum in the 
great majority of cases. Cachectic cases may be protracted even in 
the absence of complication. Cirrhosis, abscess, and gangrene of 
the lungs as sequelae imply mixed infection. The same may be 
said of tuberculosis as a sequel. The diseases sometimes coexist, 
and certain cases of apparent pneumonia pass gradually into tuber- 
culosis ; especially is this the tendency when the pneumonia is 
apicial. This sequence is of course not a transformation, but is, in 
the majority of cases, an awakening of a hitherto latent tubercu- 
losis. It must be understood, however, that a pneumonia, pur et 
simple, may run a typical course at the apex of the lungs. Catar- 
rhal pneumonia may also coincide or supervene. 

The differential diagnosis practically concerns, 1, Typhoid fever. 
Sometimes such a minor event as an epistaxis, which does not occur 
in pneumonia, or the appearance of herpes, which does not occur in 
typhoid fever, may turn the diagnosis in the early stage. Most 
cases of typhoid show diarrhoea early, whereas constipation is the 
rule in pneumonia. The temperature of pneumonia runs up rapidly, 
to reach its greatest elevation, as a rule, by the second or third day, 
while that of typhoid ascends gradually during a period of one or 
two weeks. The cloud about the brain, which so soon establishes 
the nature of typhoid fever, is absent in pneumonia, or present in 
only the last stages of the disease. In the course of a few days the 
physical signs in the chest in the one case, in the abdomen in the 
other, will usually clear up any doubt. A little later the roseola of 







PNEUMONIA. 135 

typhoid fever is distinctive. It must be appreciated that pneumonia 
and typhoid fever may coexist, and that the typhoid bacillus may 
produce pneumonia. 

2. Meningitis is sometimes confounded with pneumonia. Cere- 
brospinal meningitis is often announced in the same way, suddenly, 
with a violent chill, and both diseases may show herpes and consti- 
pation. In meningitis, however, early vomiting, opisthotonos, and 
hyperesthesia develop rapidly, while physical signs on the part of 
the lungs are wanting. In doubtful cases the diagnosis may be es- 
tablished by the discovery of the diplococcus in the sputum. The 
preparation, colored with fuchsin, decolorized with dilute alcohol, re- 
colored with methylene blue, shows the diplococcus blue in a red cap- 
sule. In seventy successive cases thus examined by Wolff the dip- 
lococcus was discovered sixty-six times, the pneumococcus three 
times, the result being negative in but one case. 
Inoculation experiments succeeded in twenty- 
two of twenty-four cases. It must not be for- 
gotten that these micro-organisms have been 
found in the nasal mucus and saliva in health. 

Thus also is the disease differentiated from, 
3, Tuberculosis. The failure to make a correct 
diagnosis is due, in the majority of instances, 

-i -it , i ' £ , >■* Fig. 97.— Diplococcus of 

here as elsewhere, to neglect of the proper ex- pneumonia in sputum . 
animation of the lungs. This is especially true 

regarding the debilitated and aged, and the remark is worthy of re- 
petition that pneumonia is a disease of age. The greatest number 
of old people succumb to this disease. 

The prognosis of pneumonia depends upon three factors — the age, 
habits, and condition of the heart. In children the prognosis is good, 
the disease having almost no mortality at this period of life. In ad- 
vanced age the mortality is estimated as high as sixty per cent. The 
disease is most fatal of all in drunkards. The existence of a chronic 
valvular disease of the heart intensely aggravates the prognosis. A 
pulse over 120 is grave. High fever is an index of gravity. Fen- 
wick (London Hospital, one thousand cases from 1880 to 1890) found 
the mortality in direct ratio to the fever. Albuminuria is grave in 
proportion to its amount. Taking cases as they come, the mortality 
averages about ten per cent. The disease is, therefore, fully as 
fatal as typhoid fever with all its complications. 

It is impossible to speak intelligently of prophylaxis without 
more definite knowledge of the mode of ingress and action of the 
cause of the disease. To inure the body by exposure to fresh air 
and by cold baths, with well- ventilated sleeping apartments, the 
avoidance of defective hygiene in every way that concerns the habi- 



136 PNEUMONIA. 

tation and the ventilation of the lungs, to protect the heart by avoid- 
ance of stimulants or mental anxieties, nearly covers the ground. 

In treatment a case of pneumonia calls for a large, well-venti- 
lated room. The temperature of the room should not be allowed to 
rise above 68°, as recorded by a thermometer at the head of the bed. 
Here it is important to remember and repeat the fact that the disease 
is not due to taking cold, and that there need be no fear in securing 
free ventilation. An abundance of pure air is of supreme import- 
ance in the treatment of this disease of the lungs. The respiratory 
centres are best stimulated, in the presence of high fever, with cold 
baths, or with baths which may begin at moderate temperatures 
^and be gradually reduced. Where for any reason baths are imprac- 
ticable, they may be substituted with an occasional dose of quinine 
or phenacetin. There is seldom call for the treatment of fever in 
pneumonia. Cough does not often demand special treatment. Any 
excess of cough may be best relieved by Dover's powder gr. ij. or 
iij., or apomorphia gr. tY~tV< or the syrup of senega 1 drachm every 
two to four or six hours. Small doses of morphia, gr. ^ in cherry- 
laurel water or peppermint water, are most efficacious. Morphia 
also best relieves pain, and, by permitting deeper respiration, best 
prevents oedema of the lungs and protects the brain. Poultices or 
other external applications to the chest are of no value except in re- 
lief of pleuritic pain. Dry cups will drain an inflamed pleura, an 
ice bag sometimes gives intense relief, but morphia, subcutaneously 
is the sovereign anodyne. Sleeplessness may be met by sulphonal or 
trional, gr. xv. in hot milk or tea, or by small doses of chloral, the 
latter always to be preceded by the administration of gtt. x.-xx. of 
dilute hydrochloric acid, or to be taken in connection with a wineglass- 
f ul of sherry wine or a dessert- or tablespoonf ul of whiskey. Where 
the heart is feeble, as in the aged or drunkards, chloral must be ad- 
ministered with caution and in minimum dose, gr. ij. or iij. In these 
cases it is often better substituted by morphine, gr. T V - -J-. Any un- 
due intolerance of the stomach may be brought into subjection by 
small doses of chloral in peppermint water, or a drop or two of 
creosote, with the tincture of nux vomica ; or, after failure of these 
remedies, by rectal injection of the bromide of sodium gr. xxx. or xl.,. 
chloral gr. v.-xv., or morphia subcutaneously gr. 4---J-. 

The real danger, as stated, lies with the heart. The best support 
in ordinary cases is alcohol in the form of whiskey, which may be 
given to an adult in dessert- to tablespoonful doses every two to four 
hours. A call for a stronger stimulant may be met with brandy,, 
with coffee, or both. Cold sponge baths always fortify the heart. 

Among the drugs the most valuable are caffeine, the soda ben- 
zoate, two or three grains every two or three hours ; strophanthine 






TUBERCULOSIS. 137 

sparteine, and digitalis. Sparteine and strophanthin may substitute 
digitalis for a short time in case of great irritability of the stomach. 
Digitalis is always best when it may be borne. The infusion, fresh, 
made from the leaves, may be given in the dose of 3 i. to 3 i. every 
two to four hours, or the tincture, five to ten drops at the same inter- 
val. The danger of the drug is in tetanizing the heart, which may be 
avoided by withdrawing the remedy so soon as the hard, wiry, digi- 
talis pulse begins to be felt. It is wise in all cases to administer some 
form of alcohol as the patient approaches the crisis, and it is not un- 
wise to stimulate moderately from the start. 

Behring, Kitasato, and the Klemperers utilized the antitoxine 
derived from the blood of immunized animals in prophylaxis and 
cure of the disease. The antitoxines in the blood serum of man 
rendered " immune by crisis " — i.e., withdrawn just after the crisis — 
proved equally effective in the experiments of Xeisser in aborting 
the disease. Such serum, withdrawn two or three days after the 
crisis, and injected, one hundred and thirty, seventy, and fifty cubic 
centimetres respectively, into the arms of patients in the height of the 
disease, cut it short within twenty-f our hours. 

TUBERCULOSIS. 

Tuberculosis is the specific infection produced by tubercles, which 
are in turn special products of a distinct micro-organism knowm as 
the Bacillus tuberculosis, or, from its discoverer, Bacillus Kochii. 

Tubercle is the diminutive of tuber, a nodule, induration, projec- 
tion mass. Though the word tubercle is as old as anatomy, the term 
tuberculosis, in designation of a definite disease, is modern. Vir- 
chow has shown conclusively that tubercle, in its modern specific 
sense, cannot be found in the works of ancient writers, who used it 
only to express a morphological meaning. It is difficult to fix the 
time when the term began, by common consent, to be limited and 
confined to the special disease, for ,the reason that the distinct isola- 
tion of the affection is an acquisition of such recent date. But it is 
safe to say that the day begins with Bayle and Laennec (1810 to 
1819) when they declared, with proof, that '•'tubercle is the cause 
and constitutes the proper anatomical character of pulmonary phthi- 
sis." As both Bayle and Laennec literally consecrated their lives to 
the study of this disease, they may be said to have earned the right 
to make, or rather to fix, its name. The word " tuberculosis " itself 
was first employed by Schonlein (1839), a disbeliever in the specific 
character of the disease. 

Phthisis — literally wasting, consumption — was the Greek name, 
as an expression of the most prominent symptom of the disease. 
Phthisis was the term for the wasting disease attended or caused by 



138 TUBERCULOSIS. 

suppurations of the lungs ; it included abscess, gangrene, suppura- 
tive pneumonias, empyemas, etc. — in short, all varieties of suppura- 
tive processes. As each of these affections was gradually eliminated 
and set upon an independent footing, phthisis came to be limited to 
the condition which, since the days of Laennec, is more properly 
tnown as pulmonary tuberculosis. 

The existence of tubercles in the beginning or course of the dis- 
ease, at some period or place in the body, justifies the adoption of the 
general name tuberculosis, while the localizations in the lungs, intes- 
tine, testis, etc., are sufficiently defined as tuberculosis pulmonalis, 
intestinalis, testis, etc. 
x The history of tuberculosis falls naturally into five periods, three 




Fig. 98. —Tubercle bacilli— sputum. 

•of which, at least, are quite distinct, in that they date from the dis- 
coveries of distinct individuals — Bayle and Laennec, Viilemin, and 
Koch. 

The first is the period of ancient history. During all this period 
the disease was observed only from a clinical standpoint. The 
second period, beginning with the birth of anatomy in the sixteenth 
century, furnishes the first definite knowledge regarding changes or 
lesions of structure. The third period followed the publication of 
the discoveries of Bayle and Laennec in the first quarter of the nine- 
teenth century, declaring tuberculosis a separate affection, due to the 
deposit of tubercle, a specific product independent of ordinary in- 
iflammation. This period is made more distinctly memorable by the 



TUBERCULOSIS. . 139 

discovery of auscultation as a means of diagnosis. It was the genius 
•of Laennec in the discovery of auscultation which first rendered pos- 
sible a diagnosis of the disease in life. The fourth period was intro- 
duced late in the last half of the nineteenth century with the inocu- 
lation experiments of Yillemin (1865) ; and the fifth was announced 
with the discovery by Koch (1882) of the tubercle bacillus as the de- 
finite cause of the disease. 

The discovery of the tubercle bacillus gave the final death-blow 
to the doctrine that tuberculosis was ever in any sense secondary. 
The spectre of inflammation, which perpetually stalked to the front 
to obscure the true nature of the disease, was quieted forever. 




Fig. 99.— Tubercle bacilli with spores, in sputum. 

Instead of producing the disease, inflammation is itself relegated to a 
secondary place in pathology as a mere result of infection. 

We may epitomize the history of tuberculosis with the statement 
that it was regarded first as a process of suppuration (pus) ; then as 
consisting of nodules, which in the third period are seen to be dis- 
tinct tubercles ; fourthly, these tubercles contain a virus ; and in the 
final period the virus takes shape in the tubercle bacillus. 

The tubercle bacillus invades the body through the lungs, in 
which it produces the disease commonly called consumption ; or, 
reaching the bronchial glands, is thence disseminated at some future 
time to the brain (meninges), bones (vertebra?, hip joint, etc.), and 
•other organs and tissues (larynx, testis, serosa?, etc.), to lead to 
sepsis and slow marasmus. Introduced into the intestinal canal with 



140 TUBERCULOSIS. 

food (milk), it ulcerates the mucous membrane, to produce diarrhoea,, 
marasmus, or fatal peritonitis. 

Tuberculosis in its various forms destroys two-sevenths of mail- 
kind. Tuberculosis of the lungs alone carries off one-sixth of man- 
kind and nearly one- third of the working class. 

Etiology. — The tubercle bacillus is a slender rod whose length is; 
about one third of the diameter of a red blood corpuscle. It is about 
five times as long as broad. It varies somewhat in size, but presents 
such nearly uniform appearance as to be used as a standard of com- 
parison for other bacilli. It lies usually slightly curved, but is often 
perfectly straight and uniform throughout its length, except where 
it is apparently broken by intervening highly refracting spherical 
spaces, four to eight in number, which are regarded as spores. Bacilli 
of rapidly developing disease show these spores in greater number.. 



^iX 







■m ; 








* 








life 






W G 


\ 












■ " -:- 


, 






kH. 






Fig 


IOC 


.—Tubercle bacilli 


in sputum 



£ 




* 

/ 






Fig. 101.— Tubercle bacilli in sputum. 

In retrograde or quiescent processes they are usually entirely absents 
The figures show various common pictures of the bacillus, with and! 
without spores, in the sputum ; also frontispiece, Figs. 10 and 16.. 
A point of singular interest is the fact that the bacillus is quite as- 
resistant to heat and destructive agents as the spores themselves. 
The Bacillus tuberculosis is distinguished by its extreme tenacity of 
life. It is invested by a membrane so dense as to be almost impene- 
trable by dyes in long saturation, or by the aid of heat. This very 
fact, however, which made the bacillus so difficult of detection, led 
later to its easier recognition ; for the membrane, having once become 
permeated, retains the color in subsequent attempts at displacement, 
so that while an original color may be displaced in surrounding ob- 
jects by a new dye, the bacillus retains its own color, whereby its. 
presence may be recognized by difference or contrast of color ; color 



TUBERCULOSIS. 



141 



Fig. 102.— Tubercle bacilli in sputum. 



"being more obtrusive than shape. Colonies cultivated with difficulty 
appear as scales upon the surface of the soil selected, usually gelatin- 
ized blood, and do not invade the substance of the soil. 

What is the original source of the Bacillus tuberculosis? All that 
is known is that it has come down to 
us. from the older civilizations. The 
Indians of our own country, the ne- 
groes of Central Africa, the inhabi- 
tants of islands of Australasia, never 
knew tuberculosis until it was brought 
to them by Europeans. So. too, tuber- 
culosis was unknown in the Xorth, 
among the Esquimaux, Laplanders, 
etc., until they received it by impor- 
tation. Once received it is propa- 
gated by direct descent.- Resistant 
as is the bacillus, so tenacious of life as to be able to live for months 
outside of the body, it is nevertheless a strict para- 
site. It may live, but not grow and multiply, out- 
side of the body. Man, with many other mammals, 
especially the cow. offers the best soil for the growth 
and maintenance of the tubercle bacillus, and the 
disease is spread chiefly by the desiccation and dis- 
semination of sputum. The sputum is nearly a pure 
culture of the Bacillus tuberculosis. Diluted 1 : 100,- 
000 times, it will still propagate the disease in the 
bodies of rabbits and guinea-pigs, animals most of 
all susceptible to the disease. Inoculation is the 
final test in a doubtful case. 

The discovery of the fact, made by Koch, that the 
disease is chiefly conveyed by the dried and disse- 
minated sputum, -met with remarkable confirmation 
in the investigations of Cornet. Inasmuch as it 
had been impossible to discover the tubercle bacillus 
in the dust-laden atmosphere, or in the dust deposits 
upon walls, ceilings, furniture, etc., of rooms in- 
habited by tuberculous patients, Cornet undertook 
to collect it under every precaution, and to establish 
its infectiveness by inoculation of guinea-pigs, rab- 
bits, and other sensitive animals. This experiment 
succeeded in two-thirds of the cases. 
It had long been noticed that relatives in close association con- 
tracted the disease from each other — husbands from wives, wives more 
especially from husbands because of the closer contact and confine- 





Fig. 103. —Colonies of 
tubercle bacillus in 
scales on surface of 
blood serum, six weeks 
old. 



142 TUBERCULOSIS. 

ment in the house. So the disease had been observed to extend 
through factories and prisons, showing a mortality equal to fifty per 
cent after a long confinement. It had been remarked, indeed, that 
confinement to prison for life is condemnation to death by tubercu- 
losis. Flick called attention to the fact that so many cases occur in 
individual houses that a house remains a centre of infection for an 
indefinite time. Seventeen of twenty-two deaths from marasmus and 
meningitis in children occurred in houses which had been infected by 
tuberculosis of the lungs and bowels in adults. Niven observed that 
twenty-six of forty-five cases were contracted in a house where death 
occurred ; sixteen in houses previously occupied by tuberculous pa- 
tients. McMullen called attention to the danger of sea voyages with 
consumptive companions in confined cabins, and the same danger has 
been remarked, though in less degree, with the discovery of tubercle 
bacilli in sleeping cars. Individuals who make the beds, dust and 
sweep rooms of patients are the most exposed. Seventy-three per 
cent of nurses up to the age of fifty die of tuberculosis. 

The tenacitj^ of life of the bacillus was demonstrated in one re- 
markable experiment, where a feather bed upon which a consump- 
tive lay was sent to five different cleaners in Berlin, and an infusion 
made of the feathers after its return the last time proved infective 
to guinea-pigs. The disease, therefore, is chiefly conveyed through 
the avenue of the lungs. Tuberculosis pulmonum is the common 
expression. The bacilli, inhaled and inspired everywhere in the 
bronchial tubes, come to lodge more especially at the apices of the 
lungs. Received anywhere in the bronchial tubes, they are more 
readily expelled from the middle and lower regions of the lungs, or 
are coughed up into the apices — parts furthest removed from the 
blood supply, regions also more quiet for growth and multiplication. 
There is no proof that the disease is ever inherited in man, though 
inheritance is assumed as a potent factor in the transmission of the 
disease. Thus it is said that of one hundred patients affected with 
phthisis, twenty-five will have had tuberculous parents ; but if we 
recall the fact that these one hundred patients had two hundred pa- 
rents, it will be seen that twenty-five represents heredity in but one- 
eighth of the cases, whereas we know already that tuberculosis is 
fatal, in the lungs alone, to one-sixth of all mankind. If the disease 
were produced by heredity it should appear first in the internal 
organs — the liver, spleen, the kidneys, etc. It should be discoverable 
also in the foetus. It is known, however, that tuberculosis appears 
first in the lungs, and in children only at the end of one or two years 
of life. Advocates of heredity maintain, to account for the absence 
of the disease in the new-born child, that the micro-organism is 
transmitted in the form of spores. The burden of proof rests with 



TUBERCULOSIS. 143 

them. In the meantime it is observed that the disease appears 
nearly always in the kings, whence it is evident that the cause of it 
is inhaled from the outside air. But when, in the more exceptional 
case, tuberculosis affects other, even distant organs, an autopsy 
reveals the existence, or the evidence of pre-existence, of caseous bron- 
chial or mesenteric glands as depots or centres of infection. The 
theory of heredity is dangerous, in that it removes attention from the 
avoidable sources of the disease. It is unsatisfactory, in that it does 
not prove enough. It is also undemonstrable : experiments made 
to prove it are all open to objection. Finally, it is superfluous. 

Certain individuals are said to be predisposed to tuberculosis. 
This predisposition is stated to be announced by an elongated, 
flattened thorax, a long, narrow neck, a thin skin with apparent 
blue veins, an enfeebled musculature, etc. This condition is de- 
clared to constitute the phthisical habitus. The truth is, these indi- 
viduals are already the hosts of the tubercle bacillus and the victims 
of the disease. Deutsch has shown that there is no predisposition in 
the configuration of the thorax, and that broad-chested men contract 
the disease as readily as those with narrow chests. It is claimed 
that certain catarrhal conditions of the mucous membrane predis- 
pose to the disease. This may be, but the fact has not been demon- 
strated. Predisposition is probably largely a matter of quantity or 
number of bacilli inhaled. Conditions which markedly interfere 
with the nutrition of the lungs may be admitted to favor the reten- 
tion and growth of micro-organisms. Thus it has been noticed that 
individuals in whom the pulmonary artery is small easily become 
victims to this disease. Congenital stenosis of the pulmonary artery 
is nearly always attended with or followed by tuberculosis. 

On the other hand, certain anatomical conditions render an indi- 
vidual less liable to be attacked. Such conditions as favor venous 
stasis or hyperemia offer obstacle to the development of tubercu- 
losis. Thus tuberculosis does not occur, as a rule, in cases of val- 
vular disease of the heart, asthma, or emphysema. Exceptional 
cases sometimes admit of explanation. Thus clinicians differ as to 
the effect of aneurism of the aorta. Aneurism of the aorta, so long* 
as it causes a venous stasis, interferes with the development of 
tuberculosis. When it, however, attains such size or disposition as 
to encroach upon the pulmonary artery, it will favor tuberculosis. 
There is probably no such thing as an individual predisposition to 
tuberculosis. A man may have weak lungs, as he may have a weak 
stomach, weak eyes, or a weak brain. This weakness may be said 
to constitute a predisposition to disease of any kind, and in this way 
only may be admitted a predisposition to tuberculosis. Degraded 
surroundings constitute the chief predisposition to the disease. 



144 TUBERCULOSIS. 

Trudeau showed that infected rabbits confined in dark, damp holes 
■speedily succumb, but allowed to run about in the open air recover 
from the disease. 

The chief source of infection — by the alimentary canal — occurs 
through the milk of tuberculous cows. Bollinger showed that milk 
may be infectious even though the udder show no signs of disease. 
Ernst and Hirschberger confirmed this fact. Dilution of the milk, 
which diminishes the relative proportion of bacilli, renders it much 
less infectious, so that it may be said, as a rule, that milk from a 
large dairy is not so dangerous as milk from a single tuberculous cow. 

Cases of infection through mucous membranes or the broken 
skin are much more rare. 

Symptoms. — Tuberculosis of the lungs begins, as a rule, insi- 
diously, and usually in one of three ways : first, as a bronchial 
catarrh ; second, with general failure of health ; third, as a dys- 
pepsia. Other individual cases begin with disturbances of men- 
struation, with metrorrhagia, more especially with chlorosis or 
amenorrhea. Other cases follow in the wake of a tuberculosis 
localized elsewhere, as in the bones of the spinal column or the hip. 
i\ ot infrequently the disease of the lungs lies latent for a time until 
brought into prominence by some intercurrent affection. Measles 
and pertussis very frequently awaken tuberculosis. In a more ex- 
ceptional case the disease appears suddenly as an acute pneumonia, 
acute pleurisy, a sharp haemorrhage, etc. 

The majority of cases begin with a bronchial catarrh. These in- 
dividuals are said to have taken " cold." They are subject to taking 
cold. On every slight exposure they take cold, and the cold distin- 
guishes itself by its persistence. They take cold with every change 
•of weather, with every change of clothing, often without any kind 
of exposure. The cold becomes more suspicious when the cough 
which marks it occurs with greater frequency just after retiring, or 
just after arising in the morning. The change in the blood current 
is invoked to account for this occurrence. 

A gradual deterioration of strength, vigor, color, appearance is 
noticed by relatives and friends. The individual is said to be "fall- 
ing into a decline." The general degradation of strength and health 
very often overshadows the cold. 

Certain poisons are evolved from the soil in which the tubercle 
bacillus grows to affect the nutrition, to produce dyspepsia. The 
menses are withheld, delayed, more especially in young girls about 
the time of puberty. In all these cases the physician entertains first 
the suspicion of tuberculosis. Pneumonias which are situated at 
"the apex should more especially excite the suspicion of a tuberculous 
basis or origin. The pleurisies which are insidious in their develop- 



TUBERCULOSIS. 145 

ment, which are not attended with much pain, but are marked by 
more profuse effusions, belong to tuberculosis. 

Bronchial catarrh becomes more significant when associated 
with physical signs. It must be remembered, however, that there 
is a. pre-physical stage of tuberculosis, often of months' duration. 
Sooner or later characteristic signs develop in the chest. These 
changes can be recognized first by auscultation. The hyperemia of 
the bronchial walls under the first irritations of tuberculosis roughens 
the inspiratory sound. The inspiration is said to be rude, like 
that of a child, puerile. Soon the elasticity of the lung tissue is 
impaired. It takes the lung a longer time to contract. Hence expi- 
ration is prolonged. This rudeness of inspiration and prolonga- 
tion of expiration is observed in its finer shades only by comparison 
with the sound side. Moist rales develop later, and these moist 
rales of bronchial catarrh have peculiar significance in their locali- 
zation. All these signs .point to tuberculosis when they are fixed 
about the region of the clavicles. 

As the disease advances these symptoms show themselves in 
greater intensity. The cough becomes more continuous, it prevents 
sleep at night, and so harasses the patient during the day as to lead 
in its violent efforts to vomiting and the loss of food. The cough 
shows itself in all grades of intensity in different cases, and in the 
same case at different times. It must be remembered that cough 
which is attended with expectoration is really salutary. Cough 
literally expectorates the disease, and it is only when it becomes so 
severe as to lead to the ejection of food, or so harassing as to pre- 
vent sleep, that it calls for alleviation. 

The expectoration becomes now more characteristic. There is 
ejected along with the frothy mucus more or less solid matter, parti- 
cles or pellets which are often pure cultures of the tubercle bacillus. 
The whole mass of the sputum becomes more solid. Expectorated 
in water, it assumes a more or less globular or coin shape and sinks 
to the bottom of the vessel. This is the sputum rotundum f nudum 
petendum of the old writers. The quantity of the sputum varies 
in every degree in different cases, and in the same case at different 
times. At times violent efforts secure nothing. Again the sputum 
is so profuse as to constitute a bronchorrhcea. Many individuals 
empty cavities in the lungs in the morning upon rising, and then 
cough no more for hours or even during the day. This is the his- 
tory of certain cases for months or for years. For the most part the 
cough varies. In states of fever, along with general dryness of the 
mucosae, there is little or no expectoration. In apyretic states it is 
apt to be more profuse. With the extrusion of sputum the true 
■character of the disease is disclosed. Whatever doubt existed be- 
10 



146 TUBERCULOSIS. 

fore is cleared up with the discovery of the tubercle bacillus or of 
elastic tissue. 

Certain cases, as stated, begin with haemorrhage. Many cases 
show no haemorrhage from beginning to end. Haemorrhage occurs 
in about half the cases. It alarms the patient at first ; it produces a 
condition of anxiety and trepidation. This apprehension, however, 
ceases with its repeated occurrence, so that later it may not excite 
sufficient alarm to secure the rest requisite for its relief. The haein- 
orrhage does a good turn at times in beginning cases by impressing 
upon the individual the nature of his case and enforcing the neces<- 
sity of treatment. Haemorrhage is rarely profuse. It shows itself, 
^ as a rule, after or in association with a light degree of fever. Cer- 
tain cases become conscious of it only on awakening. The pillow 
or clothing is stained with blood ; the taste in the mouth attracts 
attention. For the most part it is accidentally discovered as it is 
received in a vessel. In exceptional cases the patient is suffocated 
in his own blood ; the haemorrhage is so profuse as to inundate the 
trachea. Other exceptional cases where the haemorrhage is abun- 
dant but not so inundating in character literally die of loss of blood ; 
but, as a rule, haemorrhage ceases under the rest and light diet of a 
few days, or is cut short by appropriate treatment, to return or to 
recur again and again in the history of the case. Haemorrhage is not 
more common in tuberculosis because the blood vessels are blocked 
by the advance of the disease. Cases marked by haemorrhage live,, 
as a rule, as long as those in which there is no haemorrhage. 

Pain in the chest is a common expression of the disease. Infra- 
clavicular pain is always suspicious ; it is, as a rule, pleuritic. The 
pain of intercostal neuralgia from the toxic effect of the disease is 
common throughout its course. 

As the disease advances and the lung tissue is encroached upon, 
the patient becomes more and more short of breath. Dyspnoea be- 
longs to all more advanced cases, from mechanical reasons, also 
from marasmus of the heart and muscular failures. There is a 
dyspnoea which belongs to the earlier history of the disease, when 
there is no marked consumption of the lung tissue. It is a toxic 
effect. It belongs, along with the excitability of the heart — erethism 
mus cordis — in the earlier stages of the disease. 

The fever continues and becomes absolutely characteristic. Sus- 
picion of the nature of the disease in its inception is confirmed for 
the most part by the presence of the fever in the evening. The 
temperature rises from one-half to two degrees every evening, to 
subside again toward midnight, to show a normal or even subnormal 
grade in the morning. High temperatures are preceded by chills, 
and followed by sweats. Increase in fever marks new invasion by 



TUBERCULOSIS. 



147 



the organisms of pus. The chill, fever, and sweat belong to sep- 
ticaemia. Sometimes the fever is high only at noon. 

The prognosis is largely determined by the fever. In a con- 
firmed case the fever rises from the normal grade in the morning to 



Si!! X 



liiiHiii m m 

n ii in 
mmum 

BlliHiieHB 
18IB8BI88H1 
181188111188118 



Fig. 104.— Hectic (i.e., septic) fever in tuberculosis. 



104:° or 105° in the evening, to fall again the same night, and to* 
show thus such abrupt elevations and descents as to constitute that 




Fig. 105.— Phthisical thorax in a girl eighteen years old (Eichhorst). 

see-saw record characteristic of sepsis. The fever depends not sa 
much upon the extent of the disease as upon secondary infection by 
the streptococcus of pus. It does not, therefore, necessarily stand 
in any connection with the amount or degree of consolidation or 



148 TUBERCULOSIS. 

destruction of lung tissue, though, as a rule, high fever and rapid 
destruction coincide. The tubercle bacillus grows slowly. The 
streptococcus may rapidly flood the lungs. 

Phthisis, as stated, is derived from the Greek word cpQioo, to 
waste. It has its Latin equivalent in consumptio, and emaciation 
is the most characteristic feature of the disease. The people speak 
of an individual who is losing flesh rapidly as going into a decline, 
meaning thereby a subject of tuberculosis of the lungs. A loss of 
weight, along with pallor, chlorosis, amenorrhcea, erethism of the 
heart, dyspnoea upon exercise, slight fever in the evening — these are 
the symptoms which announce the inception of the disease ; but no 
one of these symptoms is so obtrusive in its further course as the 
progressive loss of weight. An individual may lose one-third, even 
one-half, his weight. The fat entirely disappears. The muscular 
tissue, the glands, even the bones, the nervous tissue least and last, 
all suffer loss of weight. Yet during the quiescent periods of tuber- 
culosis the weight may be re- 

^" ~~ ~ T 5 " ' ', ■■*■'.■] gained. Patients may thus in- 

,.M crease in weight ten, twenty, or 
even thirty pounds. An acces- 
sible scales is a valuable adjunct 
5a| in the treatment of tuberculosis. 
Along with the fever or fol- 
lowing the fever there is, as a 
j rule, more or less of a sweating 
■* — — - — - — '.'.' — — — — — — J stage. It is noticed in the early 

ihn i« t lu^i. i * -i ™ a - history of a case of tuberculosis 

Fig. 106.— Tubercular ulcer of ileum (Med. ana J 

Surg. Hist, war of Rebellion). that the skin is unnaturally moist. 

The hands are either dry and hot 
or moist and hot, clammy. Tuberculous patients are very prone to 
show discolorations upon the skin, and especially in the region of 
the sternum, from pityriasis versicolor, fungi which grow in the skin 
on account of its increased moisture. When sweating becomes pro- 
fuse it constitutes a feature of the disease, and, inasmuch as it occurs 
after the fever, it is known as night sweat. Night sweats may be so 
profuse as to saturate the clothing and bed linen to such an extent 
that the patient suffers actual cold, and the clothing must be changed 
in the night. Such sweating is sometimes colliquative. 

It is a curious fact that these night sweats come and go in the 
history of a case of tuberculosis under circumstances which do not 
admit of explanation — that is, they disappear of themselves at times 
under the same conditions as existed during their appearance. Ap- 
peal is made in explanation to the action of the sympathetic nervous 
system, to the effect of septic toxines on sweat-producing centres. 

Dyspepsia belongs to tuberculosis. Many cases, as remarked, are 



TUBERCULOSIS. 



149 



preceded or announced by an obstinate dyspepsia. It is at first due 
to the poisoning of the blood, later, to some extent, to deglutition of 
the sputum. It is the history of most cases to show, during the first 
stage of fever, constipation. Later on, far along, nearly all cases of 
tuberculosis show diarrhoea. The diarrhoea is due to the direct in- 
vasion of the mucous membrane by the tubercle bacillus as conveyed 
to the intestines by the sputum. It is also due to sepsis. 

The ulcers of tuberculosis are found in great- 
est abundance in the lowest part of the ileum 
about the ileo-caecal valve, in the same region as 
the ulcers in typhoid fever, and for the same 
reason — that is, that the bacillus received into 
the upper part is hurried along the alimentary 
canal under a more rapid peristalsis until it 
reaches the lower part of the ileum, where move- 
ment is checked that absorption may take place, 
and where time and rest are offered for the ac- 
tion of poisonous matter or poisonous micro- 
organisms. Ulcers are found in the intestines 
of tuberculous patients in ninety per cent of 
cases, and along with these ulcers, in correspon- 
dence largely with their abundance, diarrhoea, 
which becomes finally colliquative. 

Invasion of the larynx is probably always 
secondary to invasion of the lungs. It is pos- 
sible to conceive of a primary laryngeal tuber- 
culosis, and cases have been recorded in which 
a post-mortem examination has failed to dis- 
close centres in the lung. We may look, how- 
ever, with suspicion upon all these cases. Tu- 
berculosis reaches the body through the lungs, FlG : iw.-Tubercuiar m- 

» , CT . cers m the larynx and tra- 

and finds lodgment, if not in the lungs, in the cnea, seen on vertical sec- 
bronchial glands. Recent investigations show tion j «, deep nicer over the 

° . arytenoid cartilage; fr, su- 

more and more the frequency of involvement perficiai ulcers of trachea 
of the bronchial glands. It is here that tuber- ( Zie g ler )- 
culosis sleeps during the quiescent stages of the disease, and hence 
it irradiates as from a lair. Tuberculosis of the lar} r nx shows no 
sign at first different from an ordinary catarrh. Later, however, 
the hypersemia becomes more pronounced, the swelling more intense. 
Pure cultures are to be seen at times upon the surface, and with the 
erosion of tissue occur the well-known tuberculous ulcers and deform- 
ities of the disease. Tuberculous patients very commonly become 
hoarse of voice ; at times, and not infrequently, aphonic. These 
conditions are explained by the hyperemia of the mucous membrane 




150 TUBERCULOSIS. 

and the paretic states of the subjacent muscles. Later on the total 
loss of voice, together with the difficulty in deglutition, is accounted 
for by the gross destructive change. The tubercle bacilli seem to 
find a favorable nidus for development in the regions about the 
larynx, and perhaps there is no place in the body in which they revel 
in such luxuriant growth. 

In correspondence with the progress of the disease, with the loss 
of substance, and the fever, the colliquative night sweats, and diar- 
rhoea, the patient's strength becomes more and more reduced, the 
movements of the body more and more confined to the house, to the 
room, the chair, the sofa, and the bed. This progress may extend 
^ over months or years, or over the greater part of a lifetime, with ex- 
acerbations and remissions, with quiescent stages of months' or of 
years' duration. 

During the first stage of the disease the physical signs are few. 
There is no perceptible limitation to the excursion of the chest. 
Some degree of emaciation may be remarked. There is no differ- 
ence in mensuration, and no, or very slight, d inference in percussion. 
But auscultation reveals the rudeness of inspiration and prolongation 
of expiration in the early history of the disease. A little later the 
movements of the chest become more limited and in advanced cases 
almost annulled. The breathing in these cases is chiefly diaphragm- 
atic, abdominal. 

Differences in expansion may be more readily recognized by 
'mensuration. All cases of pronounced tuberculosis show a diminu- 
tion of so-called vital capacity. For practical purposes it may be said 
that the difference between inspiration and expiration in a man of 
the stature of five feet eight inches should be three full inches. In 
tuberculosis this difference is lessened. A difference of but two and 
a half inches should excite suspicion. A difference below two inches 
points strongly to the character of the disease. Percussion now 
shows dulness under the clavicles. Slight shades of difference are 
recognized best by comparison of one side with the other. Auscul- 
tation furnishes the evidence of consolidation. There is bronchial 
respiration, bronchophony, or evidence of pleuritic effusion, or great 
thickening of the layer of the pleura itself. Inspection shows now 
marked change in the contours of the chest. The thorax is flattened, 
the intercostal spaces sunken. The clavicles and scapulae stand out 
in bold prominence. It is the picture described by Aretaeus. The 
absorption of fat from the body changes the physiognomy. The 
features are sunken. A curious condition is noticed in the fingers. 
The hands themselves become so thin as to be diaphanous, and the 
absorption of the fat at the ends of the fingers gives rise to that pecu- 
liar condition called "clubbed." 



TUBERCULOSIS. 



151 




Fig. 108.— Shred 



The diagnosis rests upon the discovery of the bacillus in the spu- 
tum. When first revealed the disclosure of the bacillus took the time 
of twenty-four hours to secure saturation with color. Many subse- 
quent improvements have been made in this original process, so that 
at the present time the examination occupies scarcely 
more than fifteen minutes. The most effective means 
in general use at present is the so-called carbol-fuchsin 
test : Aquse destillatse one hundred, acidi carbolici 
crystal, five, alcohol ten, fuchsin one. A particle (of 
sputum) is placed upon a cover glass, covered and 
pressed over the whole surface by a similar glass, 
which is then drawn away. The glass is dried in the 
air, then drawn thrice, specimen side up, through a 
flame, whereupon it. is covered by the coloring fluid of elastic tissue in 
hot, then immersed one minute in the decolorizing spu um ' 
fluid — viz., water fifty, alcohol thirty, nitric acid twenty — and finally 
stained with methylene blue. Tubercle bacilli stand out red in a 
blue field. Masses of sputum should be first boiled with liquor sodse 
and allowed to deposit sediment over night. While the presence of 
a single or distinct bacillus would establish the disease, absence of 

the bacillus does not necessarily ex- 
clude it, as the specimen examined 
might not include any bacilli. Re- 
peated examination may thus be- 
come necessary. 

The diagnosis may be established, 
in a case at all advanced, by the dis- 
covery in the sputum of elastic tissue. 
For this examination no particular 
skill or apparatus is demanded. A 
morsel of sputum, preferably a gray- 
ish' or reddish-yellow particle, is 
pressed upon the slide by the cover 
glass, to reveal at once, best after the 
addition of a drop of a thirty-per-cent 
solution of caustic potash, the curled 
fibre of elastic tissue, usually, on account of its incompressibility, 
near the edge of the glass. 

In all other cases of tuberculosis, of the skin, glands, bones, testis, 
etc., as well as in all concealed, latent, or quiescent cases, the diag- 
nosis may be declared in the course of a few days by the subcuta- 
neous injection of tuberculin — one milligramme of the diluted 1 : 100 
solution — which will produce fever in tuberculosis, but will have no 
effect in other diseases or in health. 




Fig. 109— Elastic tissue with epithelium 
and bacteria. 






152 TUBERCULOSIS. 

The prognosis is determined by various factors, chief among- 
which are the habits of the patient with regard to personal cleanli- 
ness, especially with regard to destruction of the sputum. Many 
patients, by neglect of these precautions, live in an atmosphere of 
tuberculosis of their own creation, so that there is more or less con- 
tinuous auto-infection. The actual extent of invasion is a factor of 
importance, but, strange as it may appear, of rather secondary im- 
portance. A pure atmosphere free from the streptococcus of pus 
gives the best prognosis. 

The continued progress of the disease is indicated best by fever, hec- 
tic. Night sweats furnish signs of more value in a prognostic way 
^than the amount of lung tissue invaded. It must always be remem- 
bered that at any time periods of quiescence may occur, that the dis- 
ease may be brought to a standstill, that even in conditions of des- 
perate outlook improvement may take place for a time. 

The condition of the heart is a factor of value, as indicated by the 
strength of the pulse. A feeble pulse is a bad omen. The degree of 
dyspnoea furnishes striking evidence. Superficial, shallow respira- 
tion indicates rapid advance. Implication of the larynx is a bad 
sign. Well-marked laryngeal tuberculosis gives the patient not much 
longer than three to six months to live. 

Diarrhoea, especially if profuse or obstinate, indicative of more or 
less extensive ulceration, occurs toward the close of nearly all cases. 
The signs of marasmus in general, oedema of the feet, vertigo, more 
or less complete syncope, are ominous signs. 

Prophylaxis. — From what has been said already, the prevention 
of tuberculosis resolves itself into a simple problem, to wit, the de- 
struction of the sputum. True, cases are acquired in other ways, as 
by the food, milk from tuberculous cows. Tuberculosis may be in- 
troduced through the skin, but all these other ways are exceptions. 
The mass of tuberculosis comes through the lungs. It is no longer 
a question of inheritance. The theory of heredity is, as has been 
shown, superfluous and injurious. The prevention of the disease, as 
we know it, in the lungs follows as a matter of course from destruc- 
tion of the sputum. Cuspidors should stand in every room and hall 
of houses inhabited by tuberculous patients. The cloths used as 
handkerchiefs should be burnt before any drying may occur. Pa- 
tients should expectorate in water, and cuspidors or spit cups should 
be emptied twice a day. Houses inhabited by tuberculous patients 
should be subject to sanitary inspection when absolute reliance may 
not be placed upon the cleanliness of attendants. It is not necessary 
to isolate tuberculous patients. It is absolutely necessary to remove 
a child from the breast of a tuberculous mother. It is not necessary 
to prevent the marriage of tuberculous patients. 



TUBERCULOSIS. 153 

The prevention of tuberculosis depends upon the destruction of 
the sputum and the thorough boiling — i. e. , sterilization — of milk. AH 
else is trivial. With these two precautions tuberculosis will practi- 
cally cease to exist. 

The radical treatment of tuberculosis implies some address to the 
destruction of the cause of the disease, or to the rendering of the soil 
of the body infertile for its growth. Search has been made for a 
specific ever since the time the disease was known to be a specific 
affection. So long as it was believed that tuberculosis was only a 
secondary affection consequent upon other diseases, it was irrational 
to look for a specific treatment. Chlorine was introduced as a specific 
in the time of Louis, who found it valueless ; and one substance after 
another in materia medica, recommended as a specific, weighed in the 
balance, has been found wanting. All these remedies were empirical. 

The treatment of tuberculosis up to the present time consisted in 
climate and cod-liver oil,- with address to symptoms in individual 
cases. There is unanimity of opinion regarding the value of climate 
in the therapy of phthisis. Any climate which permits outdoor 
exercise is of value ; but the value increases with altitude, and in 
still more marked degree if the altitude be dry. A high, dry air is 
best suited for phthisical patients. Climatic considerations are best 
fulfilled in our country in Colorado, at the altitude of about five 
thousand feet above the sea. Wyoming, Nevada, Montana, New 
Mexico, all offer points of greater or less elevation, together with 
the comforts of life — a sine qua non. There is no contra-indication 
to climate except that which experience may furnish in an individual 
case. It has been found that cases are less liable to haemorrhage in 
the altitudes. Cases in which fevers are less marked do the best 
here as everywhere, and here as everywhere quiescent cases all im- 
prove. Many, perhaps most, recover absolutely. Latent depots- 
are often left, to be awakened into renewed activity upon return 
home. Advanced cases secure the best advantage in milder cli- 
mates. The islands in the ocean, the Sandwich Islands, the Baha- 
mas, especially Nassau, the Bermudas, are sojourns at sea without 
the disadvantages of a ship, which is to most people, as it was to 
Johnson, ' ' a prison with the additional disadvantage of danger of 
death by drowning. " Gestation at sea was recommended by Galen. 
Many cases recover in the longer trips of sailing vessels or in the re- 
peated voyages of officers, ship surgeons, etc. Mild cases, as stated, 
are benefited by any change of climate which permits life in the open 
air. The house climate in which the disease is begotten is inimical 
to recovery. A high, dry climate acts by increasing the respirations 
as well as the activity of the heart. The lungs are thus better fed 
with air and with blood. The air of altitudes is more pure ; it is 



154: TUBERCULOSIS. 

also more dry. There is less self-infection and less infection by 
sepsis. The products of the disease are more rapidly dissipated. 

Of all the internal remedies used in the treatment of tuberculosis, 
but one holds its place as having any real virtue. This remedy is 
■creosote. Testimony increases as to the value of creosote. To be 
effective the remedy must be pure. Impure preparations contain car- 
bolic acid, which injures the stomach. The patient must be saturated 
with the drug. Guttmann has shown that the tubercle bacillus will 
not grow in solutions of creosote 1 : 4000. Such saturation is impos- 
sible, but large doses are given with the best effect. It is adminis- 
tered best in mixture with equal parts of tincture of gentian or tinc- 
ture of nux vomica. The patient may take five drops of this mixture 
three times a day in an equal number of teaspoonf uls of whiskey and 
water, equal parts. The creosote mixture is to be increased a drop a 
day, the whiskey and water a teaspoon a day up to ten, whereupon 
intermediate doses between meals and bedtime should be commenced 
and increased likewise up to ten, so that the patient takes finally ten 
drops in ten teaspoonfuls of whiskey and water six times a day. At 
this time the body is saturated. Creosote is perceived in the breath, 
in the exhalations from the skin, etc., and by this time the patient 
begins to improve. It is astonishing what change takes place in cer- 
tain cases. It may be said, as a rule, that the afebrile cases do the 
best, but fever is no contra-indication. In many cases the fever sub- 
sides ; night sweats cease ; cough disappears ; the patient gains in 
weight, strength, and spirits. But not in all cases. There are many 
disappointments. There are cases which gain temporarily, to lose 
later under continued administration, and there are cases which are 
not benefited from the start. Harm the remedy cannot do. Cornet 
believes creosote acts only by improving digestion. Another expla- 
nation is offered in the neutralization of certain tuberculous toxines, 
■or in the aseptic properties of the drug, as its name implies. It is 
now known that most of the symptoms of tuberculosis are due to 
-sepsis from mixed infection. Cases in which the remedy irritates 
the stomach are very few. Exceptional cases may suffer nausea 
and aversion. In these cases the creosote may be administered 
mixed with the balsam of tolu in capsules, and gradually increased 
as before ; or the creosote may be suspended in milk. It is claimed 
that good effects are obtained by subcutaneous injection of pure creo- 
sote with pure olive oil, the oil having been rendered aseptic by 
boiling, in the proportion of one part creosote to three or four parts 
oil. The first injection may be five drops creosote and fifteen drops 
oil. The quantity is to be increased to ten or fifteen drops of creosote, 
with oil in proportion. The injection should be made in the back, 
twice daily, at a different place each time. It is attended with very 



TUBERCULOSIS. 155 

little pain. Arsenic is the next remedy, because it improves diges- 
tion and absorption. 

Tuberculous patients should be fed. Where the stomach is ex- 
cessively sensitive, milk with equal parts of Selters water, in wine- 
glassful doses every hour or two, may still be retained. A gentle 
stimulation may be offered with a light extract of malt, wine whey, 
Hhine wine, etc. Debove proposed to introduce food in large quan- 
tities through the stomach tube in the process of sur 'alimentation, 
and remarkable results were reported from this method. It is as a 
rule, however, unnecessary, as the appetite may be stimulated and 
digestion increased by diluted hydrochloric acid, tincture of mix 
vomica, or liquor potassii arsenitis, so that patients may be made to 
eat. Buttermilk, sweet-breads, fish, beef — these are the staple arti- 
cles of diet. Cod-liver oil is now made so pure as to be almost pal- 
atable. It should be given pure, not in emulsion or mixture, immedi- 
ately after meals, when the taste is blunted by satiety, in conjunction 
with or followed by an equal quantity — that is, a teaspoonful to a 
tablespoonful — of good cognac, ram. or other form of alcohol. 

The result of treatment by cod-liver oil and alcohol shows how 
much good can be accomplished by food alone. For with the previ- 
ous administration of an acid, and the after-administration of a bit- 
ter, especially strychnia, along with the cod -liver oil, the duration of 
the life of the consumptive has been fully trebled. 

In combating the special symptoms the treatment of fever merits 
the first consideration. We encounter here at once the problem of 
therapy. A successful treatment of the fever means a successful 
treatment of the whole disease, and nothing convinces the physician 
more thoroughly of the futility of radical therapy than the attempt 
to subdue or keep subdued the fever. 

The hectic of a day can be held in control by antipyretics, and the 
fever of the disease may be subdued for several days, or even for a 
week or two, by the judicious use o'f the milder remedies of this class. 
Where there is, along with the fever, irritability of the nervous sys- 
tem, anxiety, and exhaustion, it is best to use phenacetin in two- to 
five-grain doses three or four times a day, in combination with alco- 
hol, sherry wine, etc. The excessive fever of the evening may be 
prevented or subdued by a large dose of quinine, ten grains, three 
to five hours before the period of maximum temperature, but this 
remedy gives such distress that it is sooner or later abandoned. 
Salicylate of soda, salicin, or salol may substitute it in equal dose, 
or in divided doses, five to ten grains every three to six hours, with 
perceptible but less marked effect. The salicylates have also their 
•discomforts, which sooner or later more than compensate for their 
"virtues ; so that the treatment of the fever of tuberculosis in the long 



156 TUBERCULOSIS. 

run resolves itself into the general treatment of the disease, espe- 
cially by creosote. 

Mght sweats, if moderate, may be let alone. They require treat- 
ment only when profuse enough to require change of clothing in the 
night or to exhaust the patient. Remedies to control night sweats 
should be used in the following order : Sponge baths with hot, boil- 
ing, water. A hot general bath. A solution of atropia, one grain 
to the ounce ; begin with a dose of three drops ; increase on the fol- 
lowing nights to four, five, or six drops, or until there is brought 
about dilation of the pupils or dryness of the throat. Camphoric 
acid, twenty to thirty grains in capsules at bedtime. Agaric acid or 
agaricin, one-eighth to one-quarter grain two or three times a day. 
Chloral, five grains, with a tablespoon of Avhiske} T or a dessertspoon 
of brandy to counteract its depressing effect. The end will be ac- 
complished with some one of these remedies. 

Hemorrhage, if slight, or especially if frequently repeated in the 
history of the patient, calls for no treatment by drugs. In all cases 
the patient should go to bed. Hemorrhage demands absolute rest. 
More continuous or profuse hemorrhage calls for the use of atropia, 
one grain to the ounce, in dose of two to four drops every two to six 
hours up to toxic effects. Quinine, in five-grain dose at intervals of 
two to four hours, subdues the fever upon which the l^peremia and 
hemoptysis seem at times to depend. An ice bag may be put over 
the region of the heart to slow down its action. Tincture of aconite 
in drop dose every hour has been recommended for the same purpose. 
A persistent haemorrhage calls for the subcutaneous injection of 
ergotin or sclerotinic acid in half-syringeful doses every half to two 
hours. Certain individuals learn to check hemorrhage by swallow- 
ing a teaspoonful of salt, through reflex contraction. 

Cough in some degree is salutary, for patients literally expectorate 
the disease with the sputum. Some cough should, therefore, rather 
be encouraged than checked. ,The cough upon rising is of especial 
value in this regard. The cough which is so excessive as to lead to 
the evacuation of the stomach, or so harassing as to prevent sleep at 
night, calls for treatment. The same remark applies here as to 
fever, that the radical relief of cough is the cure of the disease. Pa- 
tients often say, feeling their improvement, if they "could only get 
rid of the cough " they would be well ; and so they would, but the 
cure of the cough implies, of course, the cure of the disease. Hence 
the best remedies for cough are creosote and tuberculin. 

Cough which begins to be excessive may be relieved by apomor- 
phia, to which there may be added very small doses of morphia. 
The bromides, in dose of ten to fifteen grains, may alleviate the 
cough, as a rule, however, at too much expense to the stomach. 



TUBERCULOSIS. 157 

Chloral in dose of five grains, especially if associated with alcohol, is 
a safe and pretty sure remedy for the night cough of tuberculosis. 
It counteracts also night sweats and insomnia. Later it loses its 
effect. It should never be given in dose sufficient to bewilder the 
patient or weaken the heart. 

In the effort to keep away as long as possible from opium, resort 
may be had to codeia, which may be given, with cherry-laurel water 
or bitter-almond water, in doses of one-sixteenth to one-eighth or 
one-quarter of a grain. Sooner or later we must come to morphia. 
Opium in combination with benzoic acid and camphor, as we find it 
in paregoric, in fifteen- to thirty-drop doses, may be used at first. 
Some of the evil of opium is obviated by the use of the deodorized 
tincture. An intelligent patient in the practice of the author labelled 
his bottle of laudanum the tincture of hope, on account of the long 
(years) relief it gave. The fear of the opium habit is not to be con- 
sidered in this disease. No evil is so great as tuberculosis. The evil 
is not the fear of the habit, but the disturbance of the digestive 
system. Opium seems to foster tuberculosis, hence resort is had to 
the use of it about the time when all hope of recovery is being aban- 
doned. At the same time it must be admitted that opium with its 
shield may be called into use earlier since the day of creosote and 
tuberculin. Opium alone is bad practice. Judiciously employed in 
connection with attempts at radical relief, it is not bad practice. 

In gastric catarrh dyspepsia is best avoided or relieved by regula- 
tion of the diet. Dyspepsia, which precedes the disease for months, 
is brought under control by diluted hydrochloric acid, ten to fifteen 
drops in a wineglass of water before meals. A powder of pepsin 
after meals helps it. A large wineglass of good malt, bitter or sweet 
according to taste, preferably bitter for most people, also assists it. 
Let medicated malts be avoided, and let all medicaments be admin- 
istered separately. The stomach tube should be used early and often. 

In acute miliary tuberculosis, or .phthisis florida, the stomach must 
be handled with great care. The patient may take at first equal 
parts of sweet milk and some alkaline mineral water, at the very 
first perhaps preferably the German Selters Avater. In spring and 
summer buttermilk is a most excellent drink ; it is never so good in 
winter. Sips of water excessively hot relieve nausea and vomiting 
of most acute infections. Milk may at times be taken boiling hot 
when ungratefully rejected in any other way. Per contra, certain 
cases are relieved by cracked ice. lime water and milk, or a pinch of 
soda in milk. Selters water may be had fresh from siphon bottles ; 
most of it as we get it is unfit for drink. The diet may be brought 
up gradually through the soups without fat, and fresh oyster juice, to 
the white meat of sweat-bread, fish, or fowl. Rare beef should be 



158 TUBERCULOSIS. 

introduced as early as possible in the dietary of phthisis. Eare is as- 
good as raw beef, and is infinitely more palatable. It may b& 
chopped fine and made into patties, browned upon the outside. To 
get the nourishment of beef the meat must be swallowed. Eggs 
may be used at first only when diluted, as in soups or with hot 
water or hot milk. Though nutritious, egg in substance is not easily 
digestible. Vomiting due to indigestible matter is best relieved by 
washing out the stomach with hot water, preferably with the sto- 
mach tube. Creosote with tincture of mix vomica is a most valuable 
remedy in the vomiting of phthisis. Patients under the creosote 
treatment improve as to the stomach at once. Cherry-laurel water 
<or bitter-almond water, with or without a half -grain or a grain of 
sulphate of zinc, succeeds in some obstinate cases. Bismuth or 
powdered charcoal sometimes suffices. A very potent remedy is 
chloral in three- to five-grain dose largely diluted. A mustard plas- 
ter over the epigastrium is not to be despised. 

A light diarrhoea may be allowed to run, and may be regulated 
by the diet. In such a case milk is an important element, especially 
in connection with lime water, one-quarter ; animal food. A more 
obstinate case would call for bismuth, ten or twenty grains at a 
dose after meals. It is helped at times by the addition of salol, 
five grains to each dose ; or ipecac, half to one grain to each dose ; 
or Dover's powder, one or two grains to each dose. A suppository 
containing a grain of opium at bedtime relieves the case for the 
night. A time-hallowed remedy is the tincture of opium five to 
seven drops, diluted hydrochloric acid five drops, camphor water a 
tablespoonful, every two to six hours. Patients under creosote do 
not suffer so much as others from diarrhoea. 

Pain seldom calls for treatment. Intercostal neuralgia is com- 
bated best by quinine, salol, phenacetin, or salipyrin. Pleuritic 
pain is often relieved by dry cups, hot fomentations, a hot-water bag, 
preferably a large flannel wrung out of boiling water and put about 
the whole chest. Counter-irritation with tincture of iodine or with 
croton oil is of some use. Belladonna plasters give some relief. 
They are always unsightly, sometimes uncomfortable. They accu- 
mulate dirt and interfere with the examination of the chest. 

The discovery of tuberculin established the first real epoch in 
the treatment of tuberculosis, as it constituted the first actual ad- 
dress to its cause. In beginning cases it dislodges hidden depots of 
the disease and makes manifest secreted centres. Thus it frequently 
makes a diagnosis which could not be established without it. As a 
therapeutic agent tuberculin has stood the fire of trial, so that its 
value may now be definitely stated. The use of it is contra-indicated 
in hectic and hemorrhage, and in serious affection of the intestinal 



TUBERCULOSIS. 159 

canal — conditions dne to sepsis, and best controlled, if controllable at 
all, by creosote and cognac. Tuberculin cures only pure tuberculo- 
sis. It is therefore of especial value in incipient cases of lung dis- 
ease, before sepsis has set in, and in deep-seated or secreted, latent 
cases of gland and bone affection. In these cases it soon puts a new 
phase upon the disease. Cases of anaemia, amenorrhcea, dyspepsia, 
cryptogenetic fevers, " colds/' bronchial catarrh, so-called rheuma- 
tism — in reality beginning bone caries — recurrent or obstinate laryngi- 
tis, or other of the multiform manifestations of tuberculosis, whose 
real nature was only disclosed perhaps by tuberculin, gradually yield 
under its continued and judicious use. The beginning dose should 
be small — one-twentieth to one- tenth milligramme — and gradually 
increased, avoiding fever, slowly at first, more rapidly later, up to 
ten centigrammes. The remedy should be introduced subcutane- 
ously about the back of the trunk, not oftener than every other day, 
and always in the morning, that the effect upon the temperature 
may be studied during the day. 

Tubercle bacilli are distributed from the lungs and intestines uni- 
versally over the body, but find fertile soil only in certain organs or 
tissues, as in the lymph glands (scrofula) ; serous membranes (tuber- 
cular peritonitis, pleuritis) ; brain, meninges (tumor, basilar meningi- 
tis) ; bones and joints, vertebrae, knee and hip (Pott's disease, white 
swelling, bone caries, morbus coxarius) : testicles (orchitis) ; skin 
(lupus), etc. The recognition of the fact that all these different dis- 
eases depend upon the same cause is one of the great acquisitions of 
the discovery of the tubercle bacillus. The muscles, mucous mem- 
brane of the stomach, duodenum, bile ducts, and urethra are sterile 
soils. 

Inundation of the blood and body after erosion into blood and 
lymph vessels (thoracic duct) leads to acute attacks or exacerbations 
(miliary tuberculosis, phthisis florida) ; arrest of development, gene- 
rally after destruction of tissue, to overgrowth of connective tissue 
with cicatrization and shrinkage (cirrhosis), or to caseous degenera- 
tion with subsequent softening and formation of cavities (vomicae). 
The lesions of tuberculosis outside of the lungs, larynx, brain, serosae, 
and intestine belong to the domain of surgery. 

Tubercular Meningitis. — Gruerin and Guersant in 1827 first 
set apart and distinguished tubercular from simple meningitis. Be- 
cause of the eruption of tubercles in nodular form they called it the 
granular meningitis ; and because it was found localized at the base 
of the brain it soon came to be known as basilar meningitis, in distinc- 
tion again from the simple form which affects the covering of the 
whole brain and is seen in greatest intensity at the convexity. The 



160 TUBERCULOSIS. 

knowledge that basilar meningitis is a part of the general process of 
tuberculosis is an acquisition of much more recent times, but the dis- 
ease was recognized as distinctly tubercular (1839) long before the 
direct cause of tuberculosis, the bacillus (1882), had been disclosed. 

Etiology. — Tubercular meningitis is never a primary disease, nor 
are tubercles ever first deposited at the base of the brain. Meningitis 
is a part process, a localization, a migration, a colonization of an over- 
flow from elsewhere. Post-mortem examination reveals the primary 
seat of the affection in some other part of the body, in one of the ave- 
nues of entrance to the body. Tuberculosis has its seat first in the 
lungs. The expression of the disease in the lungs may be slight, 
transitory. It may have disappeared altogether at the time of the 
examination. The lungs may show little or no lesion. Meanwhile 
the cause of the disease, the Bacillus tuberculosis, will have penetrated 
the lung substance and become lodged in the bronchial glands at the 
root of the lungs. Many of the victims of tubercular meningitis 
show the presence of tubercular glands in the neck. It is not un- 
common to have observed a chain of enlarged lymphatics above 
the clavicles and in front of the sterno-cleido-mastoid muscle. These 
glands are only outposts of more extensive internal affection. Ex- 
sections of these glands would not remove the disease or the liability 
of subsequent extension. It may be assumed, though the connection 
has never been so distinctly traced, that in some cases the affection 
arises from the mesenteric glands — that is, from intestinal tubercu- 
losis. Somewhere or other there must have been in the body a depot 
of tuberculous matter. Sometimes there is to be found tuberculosis 
of the lungs, sometimes affection of the vertebra?, Pott's disease, in- 
testinal tuberculosis, orchitis, hip- joint affection, so that the menin- 
gitis, when it occurs, though it may seem to supervene suddenly, is 
only an episode in the course of tuberculosis and in the life of a tu- 
berculous patient. Most of the children affected come of tuberculous 
stock, or live in an atmosphere contaminated by the disease. The 
evidence of local infection may be so well concealed as to have been 
overlooked, so that the outbreak in the brain is often an ugly sur- 
prise. 

Symptoms.— There may usually be elicited in the study of a case 
a history of a preceding bronchial catarrh, marked by a cough, distin- 
guished by its obstinacy to treatment, its aggravation and remission, 
its frequent recurrence. Instead of a bronchial there is sometimes an 
intestinal catarrh with the same history. The child is hence often 
more or less emaciated, easily fatigued. There is thus usually a long 
train of proclromata preceding distinct evidence of the disease. 

Cases distinguish themselves as cerebral from the start, or as gas- 
tric from the start. In the cerebral form there may be observed 



TUBERCULOSIS. 161 

more or less psychical change. The disposition of the child is al- 
tered. It is easily affected, becomes peevish, fretful, irritable, 
soon loses interest in its play, may no longer be so readily diverted, 
seems to be seized in the midst of its occupation with a kind of ab- 
straction, loses itself, as it were, for a time, gazes into vacancy, re- 
sumes its occupation with indifference or listlessness. Perhaps at 
this early period it may complain occasionally of headache. It is 
seen to put its hands to its head. It sleeps heavily, falls into sopor 
with a tendency to stupor, is longer in awakening, or is suddenly 
aroused, sometimes with a cry, a peculiar sharp cry. It grinds its 
teeth in sleep. These symptoms may pass unrecognized. The physi- 
cian is summoned because the child is suddenly stricken with con- 
vulsions or strabismus, falls into a state of coma as after a stroke 
of apoplexv, from which it recovers consciousness paralyzed, usually 
r. lore or less marked psychical disturbance. 

The scene proper opens with vomiting. The vomiting is cere- 
1 istinguishes itself by occurring suddenly, without cause, 
i >ut iausea or retching. It is copious. Cerebral vomiting 
alwa xcites alarm. One of the first questions that a physician 
s: "Has the child vomited ? " The pulse offers strong evi- 
dence. The rhythm of the pulse becomes soon disturbed. There 
is a sensation as if the pulsation was to be withheld, a retarda- 
whereupon follow several strokes in quicker succession. In 

further course of the disease the pulse becomes more and more 
retarded, though there is about this symptom no regularit}'. The 
rhythmic acts of respiration are likewise soon disturbed. In the 
very earliest stages of the disease the child stops to sigh. There is 
gaping, yawning, sighing. Later in the course of the disease the 
respiration becomes more and more disturbed, retarded or quick- 
ened. In the last stages it ceases altogether for a time, to reappear 
with a series of quicker inspirations — the so-called Cheyne-Stokes 
phenomena. 

The temperature shows the same irregularity. It is sometimes 
subnormal throughout the course of the disease. The rule is that 
there is slight elevation of temperature at first. This sign is among 
the most valuable of the earlier symptoms of the disease. It is dis- 
covered, however, only by painstaking observations. To be ac- 
curate the temperature must be taken in the rectum. 

Early in the disease there are also vaso-motor disturbances. 
The cheeks are flushed, often of a deep crimson, or blanched. 
Sometimes one side of the face is suffused, the other pallid. The 
color comes and goes quickly without emotional excitement. A line 
drawn down the surface of the body with the flat of the finger, 
across the forehead, down the cheek, a long diagonal over the breast, 
11 



162 TUBERCULOSIS. 

stomach, or thighs, blanches at first, to, in the course of a few min- 
utes, fill with blood and show itself as a crimson trace — the tache- 
rouge of Bouchut. This sign is also of value in a doubtful case. It 
indicates the spasto-paretic condition of the vaso-motors, and is seen 
also in other grave infections, as in scarlet fever. 

If the pupils be observed closely, inequalities may be detected. 
One may be found larger than the other. One is often found more 
or less contracted. In the later course of the disease the pupils 
become irresponsive to light. Under a powerful irritation they 
may both be contracted, as in opium poisoning. Last of all,, when 
effusion has taken place in the brain the pupils are dilated. 

The symptoms which indicate the direct onset of the disease are 
vomiting, headache, constipation. The child puts its hands to its 
head. It tosses about in bed with pain. It has been mentioned 
already that there is often preliminary diarrhoea from intestinal tu- 
berculosis. With the onset of the disease proper there is, as a rule, 
constipation which amounts to obstipation. Sharp purgatives f 
to move the bowels, but with this constipation there is also, a , a 
rule, collapse of the abdomen, so that the abdomen presents a 
sunken appearance, to assume a characteristic boat shape. 

The disease is often divided into stages, and while there cai 
no systematic division of symptoms, as the symptoms of the varlo 
stages so closely intermingle, no objection can be urged against 
division if this fact be held in view. 

Thus the first stage — that of irritation — is marked by hyperemia 
of the pia mater. During this stage occur the psychical symp- 
toms and the vomiting, the, early headache, the constipation. 

Next ensues the stage of eruption of tubercles in clusters about 
the blood vessels or pia, with intervening opacity of the membrane 
itself, with, also, the accumulation of some exudation, which appears 
as a milky serum about the optic chiasm and the various sulci and 
spaces at the base of the brain. In this stage the headache becomes 
more severe, intense. There are convulsions, profound vaso-motor 
disturbances, sweatings, beginning paralyses. These paralyses af- 
fect often individual muscles — the oculo-motor, abducent, facial 
groups. There is ptosis, strabismus, facial paralysis, sometimes 
hemiplegia. 

In the third stage there is free effusion. The blood vessels are 
occluded, the brain is compressed by fluid within and without the 
ventricles. The picture is now rather that of encephalitis than 
meningitis. The child lies in more or less constant stupor or coma. 
The eyes, insensitive to light or to touch, are partly filled with pus. 
The surface is cold and clammy, the pulse and respiration feeble, 
slow, and irregular. Convulsions sometimes occur, to shake with 



TUBERCULOSIS. 163 

violence this almost inanimate mass ; in one of them the heart 
ceases to beat, and death comes to the relief of the relatives and at- 
tendants as well as the patient. 

The diagnosis rests upon the fact that the child is tubercu- 
lous, comes of tuberculous -stock, or is brought up in a tuberculous 
atmosphere ; that the outbreak in the brain is preceded by a long' 
train of symptoms, whereupon ensue the psychical change, the 
vomiting, the headache, the constipation. Later on the twitching of 
muscles, strabismus, convulsions, comatose state, leave no doubt. 
The duration is short, the whole course of the disease extending 
over a period not longer, as a rule, than three to six weeks. 

The question of diagnosis seldom concerns a separation of the form 
of meningitis. The difficulty lies with the distinction of meningitis 
from typhoid fever or malaria, each of which shows more or less 
irregularity in a child. In this separation the most reliance is to be 
placed upon the thermometer. Malaria shows always a more dis- 
tinct periodicity, a more distinct enlargement of the spleen. It alone 
is really influenced by quinia. Should doubt continue, resort should 
be had to examination of a drop of blood. The regular elevation or 
step-ladder ascent of the first week of typhoid fever, and the constant 
plane of the later weeks, should distinguish this disease from the ir- 
regular temperatures of meningitis. The hebetude of typhoid fever 
is very different from the more or less periodical and paroxysmal 
mental disturbance of the first stage of meningitis. There are not in 
typhoid fever the same vaso-motor suffusions and sweatings. Men- 
ingitis is marked by constipation, typhoid fever by diarrhoea. The 
muttering delirium of typhoid fever differs from the excitements and 
convulsions of meningitis. The ophthalmoscope has revealed in very 
exceptional cases tubercles in the retina (choroid). 

The prognosis is fatal. It is assumed of a case that recovers that 
there has been an error in diagnosis. Yet there is good authority for 
the recovery of exceptional cases. 'It is claimed that post-mortems 
made upon individuals who have died of intercurrent maladies or 
by accident ha\ T e revealed lesions indicative of a pre-existent menin- 
gitis. 

The hope is in. prevention. When the health officers take charge 
of houses inhabited by tuberculous patients and secure the destruc- 
tion of all tuberculous sputum, there will be less or no tuberculous 
meningitis. Meantime much more may be done than is done in this 
direction by education of the people by the physician. 

The therapy is wholly symptomatic and palliative. There can be 
no question of the radical treatment of meningitis without address to 
the whole process of miliary tuberculosis, of which the meningitis is 
a part. 



164 TUBERCULOSIS. 

The treatment of the condition therefore implies a treatment of 
tuberculosis in general. The ice bag is put to the head more in de- 
ference to authority than from any possible use it might be. Mlsson 
claimed to have had success with the application of iodoform oint- 
ment 1 : 10, rubbed into the scalp three times a day. and brought into 
more constant application by the use of a cap. The bromides and 
chloral will relieve to some extent pains and convulsions. Resort 
may be had to chloroform or ether to cut the convulsions short. 
Morphia, internally by the rectum or subcutaneously, may give relief, 
will at least furnish euthanasia. 

Acute Miliary Tuberculosis is distinguished by the dis- 
semination of minute tubercles throughout a great part or the entire 
substance of both lungs, as well as by its general distribution over 
the whole body. It represents an inundation by auto-infection from 
some local depot, lymph gland, serous sheet, or bone deposit. 

Miliary tuberculosis is distinguished by its continuous fever, 
sustained at high degree ; by the increased frequency in respiration, 
which amounts to dyspnoea ; by pallor, cyanosis, and rapid col- 
lapse. The dyspnoea and cyanosis are main factors in differentia- 
tion from typhoid fever, especially in the presence of a roseola and 
spleen tumor, which are common to both. 

Tuberculosis of the Lymph Glands is common to all cases, 
but is so called only when the glands are affected visibly or show 
affection in signs of disease. In this regard the cervical glands are 
the most obtrusive. These glands appear as visible prominences, 
tumors, or actual deformities, to contribute to the affection commonly 
called scrofula. The tendency is toward latency with induration. 
Under stimulus — measles, pertussis, sore throat, or other unknown 
cause — the glands show signs of inflammation, usually of passive 
or subacute form. Thus they may undergo caseation or suppura- 
tion, and discharge their contents under a slow process of months' 
or years' duration, to leave finally disfiguring scars. 

Affection of other glands (bronchial, mesenteric, retroperitoneal), 

equally common but less obtrusive, 

3% *V ^jtl / ~ / * )** shows itself in signs of disease of the 

||V~ it-. —1h '"' >\«» % / lungs, intestine, and peritoneum. 

a* , % ^ \ Scrofula is usually attended also with 

C **-Jh* i ~- Ml , ^' * conjunctivitis, blepharitis, otitis, 

: ■ J '■ ** W /^^ Si ■' &bs *■'"■ ozaena, and various diseases of the 

piMU^*^ P* *"" % C Tuberculosis of the Genito- 

Fig. ilO.-Bacilhis tuberculosis in urine URINARY APPARATUS.— Tubercle ba- 

(Vonjaksch). cilli come to lodge in various parts 

of the genito-urinary tract, in the kidneys, including the pelvis, 



TUBERCULOSIS. 



165 



the ureters, bladder, and. very rarely, the prostate gland, but not in 
the urethra. The disease shows itself in dysuria and pain, and 
the urine may contain pus and blood. The diagnosis really rests, 
however, upon the detection of bacilli in the urine. The urine is 
to be filtered and the sediment tested in the usual way. 

Casss of salpingitis and peritoneal tuberculosis have been found 
to depend upon a deposit in the Fallopian tubes. A much more com- 
mon localization is in the testicles, to constitute an orchitis, which 
distinguishes itself from orchitis from other cause by its painless- 
ness and protraction. Such tumors may, however, undergo at any 
time rapid caseation and destruction. The disease begins in one 





Fig. ill. Fig. 112. 

Fig. 111.— Tuberculous caries (stiffness) of cervical vertebras. 
Fig. 112.— Tuberculous caries (gibbus) of dorsal vertebrae (Bradford). 



organ at any period of life, including infancy, and usually involves 
the other in the course of time. Other deposits may be usually dis- 
covered in these cases, especially in the lungs, and this deposit, as 
well as that 'in any other organ, may in turn serve as a distributing 
centre for disease of other organs or for general dissemination. 

Tuberculosis of the Bones and Joints. — According to the 
observations of Alfer — 1,752 cases in six years — affection of the bones 
and joints shows itself in the following frequency : knee joint, hip 
joint, vertebral column, tarsal and metatarsal bones, elbow joint, 
carpal and metacarpal bones. The disease (caries) is distinguished 



166 TUBERCULOSIS. 

in all cases by its sluggish character, long duration, deformity, and 
obstinacy to treatment. 

Tuberculosis of other organs will be discussed under appropriate 
heads. 

The diagnosis in all these cases rests ultimately upon the detec- 
tion of the tubercle bacillus, which is the central point about which 
everything else connected with the subject must revolve. 

It is only fair to say, however, that while the presence of the ba- 
cillus declares the character of the disease, absence of it does not 
exclude it, as dead bacilli dwindle and disappear. In any case the 
diagnosis may be established by the injection of a milligramme of 
tuberculin, which sets up a reaction in a case of tuberculosis. 

Prophylaxis includes removal from the air of infection, or, where 
that is impossible, purification of the air by ventilation, destruction 
of sputum, general cleanliness, etc. A scrofulous child should be 
bathed regularly and fed substantially with nutritious diet — milk, 
eggs, meats, and all kinds of fruits and vegetables. The milk 
should not come from a tuberculous mother, nurse, nor from a tu- 
berculous cow. Here, again, the condition may be determined at 
times only by an injection of tuberculin, which discloses tuber- 
culosis at times in people, especially in milk cows, apparently per- 
fectly healthy. 

The treatment in every case is the treatment of tuberculosis in 
general, by roborant diet, fresh air, altitude, cod-liver oil, tubercu- 
lin, creosote, iodine, etc., with especial address to the especial form of 
the disease. Iodine is best administered to a child in the form of the 
syrup of the iodide, gtt. x.-xxx. in double the quantity of simple 
syrup, three times a day. Where the iron may be contra-indicated 
on account of constipation the iodide of potassium or sodium may 
be preferred. Five drops of the • ounce-to-ounce solution — i.e., the 
iodide with peppermint water — may be administered before meals in 
a wineglass of milk. Swollen glands often disappear entirely under 
this treatment. Hueter recommends extirpation by means of a long 
excision along the posterior border of the sterno-mastoid muscle, 
enucleation with a blunt instrument, and dressing with the iodoform 
tampon. It is certain that the glands, though a constant menace, 
remain innocuous in many cases. 

Bone and joint affections may be sometimes reached by injections 
of iodoform. The remedy is best brought to bear upon the disease in 
the form of iodoformol — i.e., iodoform with twenty per cent of olive 
oil. Boiling sterilizes as well as makes a fine emulsion of this mix- 
ture, which when injected releases the iodoform to be distributed 
over and about the seat of the disease. The oil is not more painful 
injected hot than cold. The injection, containing iodoform 3 i. each 



LEPRA. 167 

time, should be made about once a week. Trendelenberg reports 
forty per cent of cures, or approximate cures, with this method. 

Systematic trial should be made, in all obstinate cases, of the in- 
unction treatment with massage. Green soap (sapo viridis) should 
be rubbed into the trunk and extremities twice a day for one week, 
then once a day for three days, after which, not before, the body 
may be washed clean. Remarkable results may follow this simple 
procedure. After failure with these means, or in connection with 
them, resort may be had to tuberculin in very small dose, and finally 
to the surgeon's knife. Speedy extirpation of an affected testicle 
may save the sound side, and may prevent a general dissemination 
of the disease. 

Lastly, perfectly quiescent cases should be let alone, on the prin- 
ciple " quieta non mover e ! '" On this principle the surgeon some- 
times compromises with an abscess about the hip, and always splints 
the spine in vertebral caries by a plaster jacket or other fixed sup- 
port. But here, as everywhere, cases must be individualized. Gland 
and bone tuberculosis is more apt to be a pure process than lung 
tuberculosis, which is, as a rule, complicated with subsequent septic 
infection. The apyretic is the best period for radical address by tu- 
berculin, and cases which show paroxysmal or continually recurrent 
attack of fever should be subjected to this treatment. The dose 
should be increased from one-twentieth of one milligramme, the mini- 
mum, to ten centigrammes, the maximum quantity. The remedy 
should be injected not oftener than every other day, and with strict 
regard to the temperature, i.e., to the keeping this side of fever. 
The tone and vigor of the body rapidly improve under the use of 
tuberculin, and the uncontrollable evils of septic invasion and the 
long, slow tortures of marasmus from later dissemination are 
averted in this way. 

LEPRA. 

Lepra; leprosy (AiVpos, scaly); elephantiasis Graecorum; German, 
Aussatz (set apart, isolate). — A chronic infection, chiefly of the skin 
and nerves ; produced by a special bacillus ; characterized by infil- 
tration and destruction of tissue, disturbance and destruction of sen- 
sation (anaesthesia), and slow, progressive marasmus. 

History. — Lepra, the famous plague of the Old Testament, was 
the most dreaded disease of antiquity and the most formidable foe of 
mankind. On account of its deformity, infectiousness, and incurabil- 
ity, victims of the disease were shunned and set apart. The term 
' ' leper " is still a contumely. With the advent of syphilis in the fif- 
teenth century leprosy began to recede, to occupy finally a subordi- 
nate role, so that the disease is now seen in Europe only in Norway 



168 



LEPRA. 



and Sweden, Turkey, along the borders of the Mediterranean; and, in 
America, in the Sandwich Islands and in the southern part of our 
own country (Florida and Louisiana), though it still prevails in epi- 
demic proportions in the East. The luminous period in the history 
of the disease was the discovery of the Bacillus leprae by Hansen and 
ISTeisser in 1879. 

Bacteriology. — The Bacillus leprae is a slender, delicate rod, about 
half as long as the diameter of a red blood corpuscle. It resembles 
closely the Bacillus tuberculosis, and is usually disclosed in the same 
way, but differs from it in that it may be stained in acids, eosin, and 




WMSMfA 

Fig. 113.— Leontiasis leprosa (Munch). 

acid f uchsin — a fact which led to its earlier recognition. The Bacillus 
leprae has been cultivated on gelatinized blood serum and cooked egg. 
Authorities differ regarding the possibility of inoculation of animals 
and the mode of ingress into the human body. The best bacteriolo- 
gists deny any hereditary transmission. Lepers live for years in inti- 
mate (family) relation with others without ever conveying the dis- 
ease. It is certain that the bacillus or its spores may lie latent in the 
body for a long time, for months or years. It is usually dissemi- 
nated through lymph channels, more rarely by the blood (vide Fron- 
tispiece, Fig. 1). 

Symptoms. — The soils of selection in the body are the skin and 



SYPHILIS. 



169 1 



nerves, but other organs, the liver, spleen, and testicle, are often 
visited en masse. 

In the skin, especially of the face, knees, elbows, and backs of the 
hands, lepra forms masses or tuberosities, which slowly increase in 
size, to produce characteristic deformity (leontiasis) or ulceration 
with destruction. The destructive process slowly extends, to invade 
deeper tissues and organs. In fact, lepra may attack any part of the 
body ; the hairy scalp and glans penis alone 
escape. 

Nerve tissue is irritated, thickened, and 
finally destroyed, with symptoms at first of 
hyperesthesia and pain, especially in the do- 
main of the ulnar, median, and peroneal 
nerves, and later anaesthesia, not infrequent- 
ly paralysis. Trophic change, discolorations, 
morphcea nigra et alba, and pemphigus are 
common expressions of the disease. Every in- 
vasion is attended with that rapid multiplica- 
tion of cell elements which constitutes the 
" granulation tumor." 

The incubation runs from three to five 
years (Hansen). The course lasts for life, 
which it usually abbreviates with deformities 
to which the patient grows indifferent. 

Prophylaxis and Treatment. — As the 
mode or avenue of invasion is unknown, and 
as the disease is general or constitutional when 
first seen or recognized, the only prevention consists in destroying ex- 
creted matter, and isolation of patients, whose lot should certainly be 
made as comfortable as isolation admits. Periods of latency or 
quiescence, even of years' duration, must not be mistaken for cure of 
the disease. Treatment is as yet symptomatic and empirical. Unna 
claims to have cured cases with the internal administration of the 
ichthyo-sulphate of soda and local applications of ichthyol and pyro- 
gallic acid. 

SYPHILIS. 

Syphilis, sive morbus Gallicus (Fracastorius, 1530) ; pudenda- 
gra, lues venerea, pox ; etymology unknown (possibly ffvs q)i\eiv, 
mutual love). — An exclusively human infection, of venereal origin, 
inherited or acquired, distinguished by a long period of incubation, 
two to four weeks, a primary sore at the point of inoculation, with 
subsequent glandular enlargement ; a second stage marked by sore 
throat, cutaneous eruptions, and condylomata ; a third stage with 
fall of the hair, disease of bone, and finally of internal organs. 




Fig. 114.— Mutilating lepi'osy. 



170 SYPHILIS. 

S} r philis formerly included other venereal diseases — gonorrhoea 
and chancroid. Knowledge of true syphilis dates from 1493 A.r>. 
Definite information and differentiation from gonorrhoea was fur- 
nished by Ricord, 1838. The contest between the unicists, who 
maintained that the varieties of venereal disease were but different 
expressions of the same malady, and the dualists, who maintained 
that each disease was separate, was decided by Ricord, . who, with 
overwhelming proof, established the fact that syphilis is a constitu- 
tional, chancroid a strictly local disease. No other venereal disease 
than syphilis is or becomes constitutional. Chancroid may involve 
the lymphatics and produce buboes, the sore itself may become gan- 
grenous, but chancroid is never systemic. So, also, gonorrhoea may 
affect the lymphatics of the groin, may extend to the bladder, in 
women also to the uterus, tubes, ovaries, and even to the perito- 
neum, it may invade the joints, but it never causes late constitu- 
tional disease. 

History. — Gonorrhoea and chancroid have been known from 
time immemorial. Syphilis, as stated, entered Europe and was first 
described as a form of venereal disease about 1493. It appeared be- 
fore Naples and spread through Italy with the invading French 
army. During the following years it raged violently throughout all 
Southern Europe. The primeval origin is unknown. The period of 
its appearance was a period of adventure and exploration. America 
was discovered and Africa explored. Certain medical historians de- 
rived the disease from America, but there was no history of syph- 
ilis among the indigines until it was introduced from Europe. With 
more reason it is supposed to have been imported from Africa by 
Portuguese explorers. With its first recognition it was certainly a 
new disease, but within ten years it spread over the whole civilized 
world. The filthy personal habits and the peculiar social customs of 
the time explain its rapid diffusion. Ricord believed it to be a trans- 
formation of glanders ; Simon considered it a form of leprosy. It is 
now known to be specific, sui generis. The confusion which so 
long prevailed regarding the identity of venereal diseases was partly 
due to the fact that two or more affections may be conveyed at the 
same time. It is possible at one impure intercourse to contract syph- 
ilis, chancroid, and gonorrhoea, with scabies or pediculi. 

Syphilis is distinguished by its long period of incubation. The 
first manifestation appears in two to four weeks, usually not later 
than the twenty-first day after infection. Any lesion which appears 
before the lapse of two weeks is almost certainly not syphilitic. 

Etiology. — The disease may be conveyed, aside from sexual in- 
tercourse, through the medium of utensils, drinking vessels, towels, 
by contact of other parts of the body, as of the lips in kissing. Phy- 




SYPHILIS. 171 

sicians have become infected in the manipulation and treatment of 
a, case, more especially in obstetric service. 

Syphilis is introduced only by inoculation, whereby is required a 
break of the surface. Slight lacerations, abrasions, or other lesions 
■of the genital mucosa suffice to give it entrance. 

Bacteriology. — Lustgarten ascribes pathogenic properties to a 
bacillus much like that of tuberculosis. It is 3 to 7 /* long and 
somewhat enlarged at the ends. It is demonstrated with difficulty, 
best, according to Muschalk, in the hot Lof- 
tier solution with subsequent stain with vesu- 
vin, when the bacilli stand out blue on a 
brown field. Cultivation has not yet been 
successful. The pathogenetic relation of this .jzt- 

organism is not yet definitely established; >. % 

for it speaks the facts that it may be found 
in all kinds of syphilitic lesions, and that it V ¥ 

may be now distinguished by the carbol- FlG . ns.-Lustgartens ba- 
f uchsin test from smegma bacilli,; from which cillus of syphilis. 
it could not hitherto be separated. 

Hereditary Syphilis. — Either parent affected with syphilis, 
manifest or latent, may communicate the disease to the foetus. The 
child may be affected during birth by disease of the soft parts of the 
mother (congenital syphilis), at conception by diseased ova or sper- 
matozoids, or during gestation through the blood (hereditary syphi- 
lis). Further, a father may communicate the disease to the child 




Fig. 116. Fig. 11T. ' Fig. US. 

Teeth in hereditary syphilis (Hutchinson). 

through the spermatozoids. while the mother escapes altogether or is 
subsequently affected by the child. 

The foetus thus affected may perish in utero and be discharged. 
Habitual abortus is frequently due to this cause or to placental 
syphilis. More frequently the child is carried longer and birth is 
premature. The child then, or later, shows evidence of the disease 
in feeble constitution, stunted growth (arrested development), notched 
teeth, etc., or in actual eruption of papules, vesicles, and scales upon 
the palms of the hands and soles of the feet (pemphigus and psori- 
asis). Coryza, caries of bone, periostitis, keratitis, are other evidences 



172 SYPHILIS. 

of infection. In the vast majority of cases of hereditary syphilis the- 
disease shows itself within three months after birth. In a small 
proportion, ten per cent, it may be delayed up to six months — syphi- 
lis hereditaria tarda. 

As the disease expires in the parents, subsequent conceptions 
show less and less infection, until finally children are born healthy 
and at term. 

Symptoms. — The first sign of syphilis appears at the site of in- 
oculation in the form of a chancre (from cancer), ulcus durum, a 
papule, upon the summit of which is formed a small vesicle whose 
rupture leaves a cup-shaped depression. The chancre is peculiar in 
having an indurated base. This induration, which is best detected 




Fig. 119.— Syphilitic roseola with malformation of teeth (Keyes). 

by pinching up the papule between the fingers, is almost pathogno- 
monic. It constitutes what is called the initial sclerosis. The sore 
lasts, as a rule, at least three or four weeks, often as many months. 
It may reappear after having subsided, and this process may be 
repeated. 

In the female the initial lesion is usually located upon the inner 
surface of the labia or on the vaginal portion of the cervix. In 
these situations it appears as a flat or slightly elevated sore without 
the distinct papular character. On account of its location and char- 
acter it is frequently overlooked. 

By the time the induration of the chancre is well developed there 
is enlargement of the inguinal glands, usually more marked in one 



SYPHILIS. 173 

gland, forming the so-called indolent bubo. The common seat of 
bnbo is in the groin. ' If the hand is the site of the primary sore, the 
glands back of the elbow, the cnbital or post-cubital glands, first en- 
large. The situation of the chancre determines the site of the bubo, 
in that the nearest glands are the earliest affected. 

A month may now elapse without further manifestations, after 
which time lesions show themselves in the skin. The eruption upon 
the skin is often j)receded by malaise, chill, fever, and other evi- 
dences of systemic affection. It appears as a roseola over the fore- 
head, chest, shoulders, abdomen, and may be distributed as an 
efflorescence over the whole body. 

The syphilitic roseola is to be distinguished from measles by the 
fact of its occurrence in an adult, by its brighter color, the broader 
basis of the eruption, and by the history of the case. The initial 
sore may usually still be found at this time. The eruption has fre- 
quently a coppery hue, a pigmentation, 
the result of prolonged irritation of the 
skin. It is not always seen in syphilis, 
and does not belong especially to this 
disease. 

Following the early eruption of sec- § 
ondary syphilis occur others represent- 
ing nearly all t he various form s of dermal % 
disease — e.g.. small and large papular 
eruptions, acne; small and large pustu- 
lar eruptions, ecthyma, etc. Destruc- " <an \ "!.' * . 

r ' u Fig. 120.— Syphilis of the larynx with 

live pustular, tubercular, and gumma- great deformity. 

tous lesions belong to the later (tertiary) 

•stage. Syphilis in the skin is distinguished by its polymorphism. 

.Several different varieties of eruption may frequently be found at the 

same time. 

By the time of the first eruption, there is generally enlargement of 
the lymphatic glands. All the glands may become affected, and the 
disease is distinguished by the involvement of glands which in other 
diseases usually escape, as the glands behind the sterno-mastoid 
muscle and those behind the elbow. 

About the same time lesions appear upon the mucous membrane 
of the throat. The throat becomes hyperaemic, especially the arch 
of the palate and the pillars of the fauces. There is usually some 
angina. The nose is similarly affected. Later in the course of the 
disease destructive lesions develop in the throat and nose. They 
may not remain confined to the soft palate, but may extend to the 
larynx, beginning, as a rule, upon the lingual surface of the epiglot- 
tis. Laryngeal tuberculosis, on the other hand, usually begins on 




174 



SYPHILIS. 



the posterior surface. No disease deforms the nose and throat more 
than syphilis. The sunken bridge of the nose is a characteristic 
lesion. 

Among the most prominent of the lesions of secondary syphilis 
are the condylomata. These patches or plaques are the most com- 
mon sources of infection, since they last much longer than the pri- 
mary sore. They occur not only upon the mucous membranes, but 




Fig. 121.— Tubercular syphiloderm of face (Hyde). 

upon the skin where it is moist and subject to intertrigo, as about 
the vulva, nates, and under the breasts. They differ from gon- 
orrhceal condylomata, which have a drier surface and a more raised, 
warty, or cauliflower appearance. 

The eye is involved. There is wont to appear an affection of the 
iris during the secondary stage of syphilis, which demands immedi- 
ate dilatation of the pupil to prevent adhesion to the lens. Keratitis 
is common later. The choroid, the retina, the optic nerve may be 



SYPHILIS. 175 

affected at any time. Paresis and paralysis of the eye muscles are 
not infrequent. 

During succeeding years symptoms may appear and disappear 
repeatedly. 

The tertiary lesions upon the skin are chiefly pustular, ecthy- 
matous in character. Syphilitic rupia is characteristic. It consists 
of pustules which scale over, break down, and form scales again. 
The crust is therefore laminated in structure and appearance, like an 
oyster shell. Large pustular lesions not covered in this way are 
called tubercular. They occur most frequently upon the back 
about the sacrum. All these lesions of syphilis destroy tissue and 
leave scars. They are sometimes attended by itching, which does 




Fig. 122.— Syphilitic necrosis of cranium (Eichhorst). 

not occur in the secondary eruptions. These late manifestations are 
not infectious or contagious. 

The affection of the bones is characterized by a peculiar noc- 
turnal exacerbation, ascribed to pressure from distended veins. 
Subcutaneous nodes develop, especially upon the sternum, clavicle, 
and spine of the tibia. Changes in the structure of the bones may 
occur in any part of the body, either in the direction of necrosis or 
eburnation. 

Syphilitic disease of the internal organs" belongs to the tertiary 
period. It occurs, as a rule, very late — ten, twenty, or more years 
after the primary lesion. It is often recognized by the fact that 
syphilitic manifestations have occurred at intervals during this 
period. 

On the part of the nervous system pressure symptoms, more 



176 



SYPHILIS. 



especially incomplete paralysis, may arise as the result of exostosis 
from the cranial bones or spine. Tumors of the brain and cord may 
have this origin, or may consist of gummata, more distinctively 
characteristic of the disease. 

A certain change affects the bloodvessels, as an endarteritis 
obliterans, which gives rise to regions of softening in the brain and 
cord. Syphilis attacks the nerves themselves, especially the third, 
fifth, and seventh. The muscles, though rarely, are sometimes in- 
vaded. There is a syphilitic myositis, most frequent in the deltoid 
muscle. 

The lungs are attacked more frequently in hereditary than ac- 
x quired syphilis. It is often difficult to distinguish the disease from 




Fig. 123.— Syphilitic endarteritis (Baumgarten): 1, endarteritic growth; 2, new tunica fenes. 
trata ; 3, old tunic; 4, gummata in the adventitia; av, adventitia; ms, muscular coat. 



ordinary phthisis due to tuberculosis. It is said to attack the 
middle portion of the lung rather than the apices. It does not give 
rise to cavities, and is more amenable to treatment than tuber- 
culosis. 

In the liver syphilis causes a form of cirrhosis, a proliferation of 
the connective tissue (diffuse hepatitis), compressing the vessels, and 
followed by all the signs of ordinary cirrhosis. Gummata frequently 
appear in the liver, sometimes to produce a nodular condition which 
may simulate carcinoma. With these lesions some external evidence 
of the disease can usually be found. 

Syphilis causes a peculiar sarcocele, which may be of large size, 
involving the whole testicle. It is usually of slow growth and not 



SYPHILIS. 177 

painful. It is distinguished from the tubercular disease by the fact 
that the latter affects the structure proper of the testicle, and is,, 
moreover, usually accompanied by tuberculosis elsewhere. It differs 
from gonorrhceal epididymitis in the absence of fluid within the 
tunic. 

The diagnosis of syphilis can usually be made by observing the 
polymorphism but symmetrical distribution of its eruptions, the 
glandular enlargements, and the changes in the bones. Suspicion is 
often aroused during inspection of the patient by the condition of the 
eyes, nasal bones, the presence of cicatrices or pigmentations in cer- 
tain localities — shins — or the detection of an ozsena. The diagnosis 
is sometimes only definitely established by the results of treatment. 

The prognosis is for the most part favorable. The manifesta- 
tions can usually be controlled. Deep-seated lesions due to syphilis 
are, as a rule, more amenable to treatment than when dependent 
upon other cause. 

Treatment. — The initial lesion is best treated upon an expectant 
plan. It is sufficient to make soma local application, as dry calomel, 
iodoform, or bismuth. Excision is no longer practised. 

Those patients have, as a rule, the best prospects in whom gene- 
ral, specific treatment is begun latest. It is not best to endeavor to 
prevent the secondary lesions, which are harmless. When, however, 
destructive changes threaten (palate, nose) it is necessary to inter- 
fere. 

Specific treatment may be postponed till the disease has reached 
full efflorescence. This can rarely be done in practice. So great is 
the popular fear of the disease that it is usually necessary to begin 
treatment at once. The treatment, then, should be mild at the start, 
a syrup of sarsaparilla or mild Zittmann's decoction. Unfortunately, 
both physician and patient are impatient for results. 

Mercury is specific for syphilis. This fact was known long ago 
(manna metallorum), but the drug , was given so recklessly and for 
all the venereal diseases that some of the late lesions were often erro- 
neously ascribed to the treatment. 

The best form in which to administer mercury internally is calo- 
mel. The method of the Vienna school is as follows : One grain is 
given three times daily for five days ; the dose is increased one grain 
every five days for twenty days. One to- three-grain doses are then 
continued for twenty days longer. 

If the bowels are too much affected they may be confined by 
opium. Ptyalism is to be met by the use of potassium chlorate, satu- 
rated solution, a teaspoonf ul every two hours. The evils of ptyal- 
ism have been much exaggerated. They are as nothing compared 
with the late lesions of syphilis, against which thorough treatment 
12 



178 CHANCROID. 

offers the best protection. The best effects are to be obtained by the 
inunction method. A small mass of mercurial ointment, a piece as 
big as the end of the little finger, is rubbed between the hands, as a 
barber rubs hair oil before applying it, and is then applied at bedtime 
with friction for five minutes to the body in the following order : 
Forearms, arms, chest, abdomen, thighs, legs — one part each night, 
to avoid eczema. The body should be bathed but once a week. 

The treatment should be continued for weeks or months, or up to 
slight ptyalism. Thereupon mercury should be given in small ,dose, 
as the biniodide gr. T V in pill, one to three times a day for a 
year or two, that the remote evils of the disease may be avoided. 
The iodides of potassium and sodium furnish quicker results in ter- 
tiary forms (gummata). They should be administered in milk in 
doses of ten to thirty grains before meals, and be kept in circu- 
lation by free libations of water (mineral waters). Iodine and mer- 
cury may alternate as remedies in the treatment of syphilis, which 
should be continued, with intervals of rest, for full}^ two years. 
Thus only may the patient certainly escape the terrible remote se- 
quehe of syphilis — amyloid change, locomotor ataxia, brain soften- 
ing, etc. 

CHANCROID. 

Chancroid (like chancre) ; ulcus molle, " soft sore." — A specific 
(venereal) sore which appears, in twelve to twenty-four hours after 
infection or inoculation, about the frenum or other portion of the 
glans penis, as a red spot, which is elevated into a papule and con- 
verted into a vesicle in the course of another day or two. The vesicle 
ruptures to leave an ulcer with sharply defined, often overhanging 
borders, and a ragged, profusely suppurating base. The chancroid 
is always i?ioculable, in the ape a,s well as in man, to reproduce it- 
self on any broken surface of skin or mucous membrane. Hence, by 
auto- or reinoculation, chancroid is often multiple. It often infects, 
neighboring lj-mph glands, and is a common cause of the rapidly 
suppurating bubo. Under bad surroundings and in depraved con- 
stitutions it may spread to form more extensive and destructive 
lesions, phagedenic (serpiginous) or gangrenous in character ; yet it 
is always a local process, and is never followed by signs of infection 
of the blood. These two features, the rapidity of onset and local con- 
finement, distinguish the chancroid from the true chancre (syphilis) . 

The treatment is simple. If seen early it should be destroyed, 
best by fire — galvano-cautery, Paquelin's thermo-cautery, ferrum 
candens ; or where from any reason this procedure is impracticable, by 
strong caustics — caustic potash or the zinc chloride in stick. Nitrate 
of silver is too superficial ; it does more harm than good, in that it 



GONORRHOEA. 179 

only adds to the irritation and favors the development of buboes. 
Fuming nitric acid, applied with wood (match), is very effective. 
After the first few days the treatment must be mild. The surface 
should be thoroughly cleansed and dusted with iodoform as the best 
remedy, or, next, with dermatol, or calomel or bismuth. Sometimes 
it is best to use these remedies in the form of an ointment rubbed up 
with vaseline or lanoline, sometimes as a wash (black wash), or sub- 
limate solutions 1 : 1000-5000. 

Buboes at the start may sometimes be aborted with an ice bag ; 
later they must be poulticed and freely incised. Rest in bed is the 
best remedy. 

GONORRHOEA. 

Gonorrhoea (yovjj, seed, semen) ; blennorrhcea (fiXevva, mucus, 
pi go, to flow), from ancient erroneous views of the nature of the dis- 
charge ; urethritis specifica ; clap ; German, Tripper. — A venereal 
infection of the urethra, caused by a special micro-organism, the 
Gonococcus, and characterized by d} T suria with discharge of pus, 
adenitis (bubo), condylomata, sometimes by affection of the prostate, 
testicle, bladder, kidneys (pyelitis), Fallopian tubes (salpingitis), and 
occasionally followed by inflammation of the joints (gonorrhoeal rheu- 
matism). 

History. — Gonorrhoea dates from the most remote antiquity. 
The Jews were very well acquainted with the disease, and they, with 
older nations, practised circumcision in prevention of it and in pro- 
tection against it and other evils (balanitis). The museum at 
Naples exhibits catheters and dilators (bougies) exhumed from Pom- 
peii. Syphilis on its appearance was known to be distinct from gon- 
orrhoea, but was later, after Hunter's unfortunate double inoculation 
of himself, confounded with it, to be only finally dissociated by the 
more extensive observations of Ricord (1838). The Micrococcus gon- 
orrhoeae was discovered by Neisser in 1879. 

Etiology. — Gonorrhoea is contracted in impure sexual inter- 
course by the introduction into the urethra of a specific cause, a par- 
ticular micro-organism, which may be thence disseminated to any 
part of the genito-urinary tract. The disease has therefore a very 
wide range, and is wont to secrete itself in some recess or lacuna of the 
posterior urethra, prostate gland, Fallopian tube, as a malady often 
of years' duration (gleet, oophoritis, etc.). Intense or protracted in- 
flammation, heroic treatment, as with concentrated injections, may 
develop stricture of the urethra with its attendant evils. Lack of 
cleanliness, or careless manipulations, may convey the discharge to 
other mucosae, as to the anus (condylomata) or eye (conjunctivitis). 
The eye, more rarely the vagina, of the new-born child may be in- 
fected during birth (conjunctivitis, blennorrhcea neonatorum). 



180 



GONORRHOEA. 



The disease is most readily contracted with filthy habits, and is 
favored by conditions which retain secretions— phimosis, hypo- 
spadias, balanitis, etc. The tougher mucosa of the vagina is more 
resistant, so that females are less affected, or, while actually con- 
taining the virus to convey the disease, may themselves escape all 
infection. 

One attack predisposes to others, which are, however, aside from 
complications, successively milder as a rule. 

Bacteriology— The Gonococcus is a diplococcus, apparently com- 
posed of hemispheres separated by an equatorial zone. It is found 
in gonorrhceal pus in association with other pyogenic cocci, from 
' some of which it is differentiated with difficulty. It grows on blood 
serum as a thin, yellowish-gray coat with smooth surface, only at 
high temperatures, and speedily perishes. It takes the color of the 






W 




@ >£* #fc W 



•/'Jr 3 



h *3» W 






# 9 m 



a -A ••'•&•> **&-*' ... west ■ 

w %$ m . & 

Fig. 124. Fig. 125. 

Fig. 124.— Gonococcus (Sternberg) : a, pure culture ; b, in pus, and c, in epithelial cells. 
Fig. 125.— Gonococcus in pus cells. 

aniline dyes, and gives it up under the Gram method. It is found 
incorporated in pus cells, as well as free in the matter discharged 
(vide Frontispiece, Fig. 5). It is found in the tissue of the urethra, 
incorporated in as well as between the epithelial cells and leucocytes. 
It has been traced, throughout the whole range of the disease, in the 
prostate, testicle, Fallopian tubes, perimetritic processes, and joints, 
and in the eye as the cause of a specific acute conjunctivitis and of 
a specific chronic trachoma. 

Symptoms. — The incubation is two or three days, at the end of 
which time tingling, then burning, and later scalding sensations 
are felt in the urethra on passing water. The under surface of the 
penis (urethra) is tender ; the lips of the meatus become tumid, red, 
and dry, or stick together with glutinous mucus. Erections assert 



GONORRHCEA. 181 

themselves, especially at night, to produce excruciating pain and 
distress with deformity (chordee). In the course of a day or two 
muco-purulent matter, and later pus itself, is voided, at first with the 
nrine, later more or less continuously, or may be at any time more 
freely expressed. In the height of the average case there are fever 
and general distress. Bad cases may be marked by destruction of 
tissue, erosion of the capillaries, with discharge colored by blood 
(Russian clap). 

In certain cases infection travels along the lymphatics to reach 
and inflame the nearest glands in the groin, a chain of which 
constitutes a painful, indurated mass, filling the groin on one or 
both sides, and putting a stop to locomotion. In other cases the 
disease extends to involve the posterior urethra, pars prostatica, vas 
deferens, and epididymus, which swells with great pain and effu- 
sion into the tunica vaginalis (acute hydrops). Moist surfaces of 
mucous membrane or skin suffer maceration and irritation, with 
hyperplasia of papillse, to produce the warty or cauliflower condylo- 
mata so common on the glans penis and not uncommon in the peri- 
neum. A more acute inflammation of the prepuce, as produced 
especially by lack of cleanliness, retained secretions, or by fissures 
from retraction, may result in phimosis or paraphimosis. 

In certain cases the clap involves the posterior urethra in due 
sequence, usually in the course of the second or third week, to pro- 
duce posterior urethritis and prostatitis. In certain other cases 
the posterior urethra and prostate are seemingly involved first, the 
disease having been latent at the fossa navicularis and pars pendula. 
In either case, whether with evident or absent discharge, there is 
dysuria, with more or less constant desire to micturate, often with 
sudden stoppage of the flow from spasmodic contraction of the bulb. 
Perturbations in the psychic sphere, irritability, dejection, emotional 
disturbance, hysteria virilis, along with insomnia, headache, 
priapism, occur with this complication, which is very much more 
frequent than is commonly known. 

Involvement of the glands of Cowper, usually not before the third 
week, is revealed by a sense of weight and pain in the perineum, 
with the formation of a tumor in the line of the raphe under the 
skin, which is movable above it. The tumor may recede by resolu- 
tion, or continue to enlarge to involve the skin in a suppurative 
process, and discharge itself externally with relief of previous dis- 
tress, or internally with the bad signs of infiltration of urine and the 
formation of fistulse. 

Peri-urethral and prostatic abscess, purulent cystitis, pyelitis, 
subsequent stricture of the urethra, are not uncommon complications. 
Women are affected with vulvo-vaginitis, vaginitis (leucorrbcea), 



182 GONORRHOEA. 

metritis, oophoritis, salpingitis, sometimes with peritonitis, as the 
result of gonorrheal infection, much more frequently than is com- 
monly believed. In this way gonorrhoea is a frequent cause of 
sterility. 

Gonorrhoeal rheumatism attacks most frequently the knee joint, 
one or both, and one joint rather than a number, usually late in the 
history of the disease, and distinguishes itself by its sluggish, passive 
character (hydrarthrosis) and exceeding obstinacy. The heart is not, 
or is only very rarely, aff ected. 

Duration, Prognosis. — Gonorrhoea usually lasts, aside from 
complications, two to four weeks. It may be terminated earlier by 
felicitous treatment, or may by bad treatment or by complications 
(prostatitis, salpingitis, etc.) be protracted to constitute a lifetime 
malady. The prognosis of urethritis is favorable; that of the com- 
plication depends upon its nature. The disease is often very obsti- 
nate and shows constant tendency to recur. On the whole, though 
apparently a simple local affection, gonorrhoea is, on account of its 
complications, more destructive of comfort, more defiant of treat- 
ment, and absolutely, in the long run, more dangerous to life than 
syphilis. But it is not so insidious and treacherous as syphilis, and 
hence is not so much feared or loathed. 

The prophylaxis is purity and cleanliness. The eye affection of 
infancy is best prevented by vaginal irrigations with a weak subli- 
mate solution 1 : 10,000 before labor, and washing out the eyes im- 
mediately after birth with a solution of nitrate of silver in distilled 
water two per cent. 

The diagnosis is in most cases easy. The history is sometimes a 
help ; often, on account of misrepresentation, a hindrance. The ure- 
thritis with dysuria and discharge, subsequent adenitis or epididy- 
mitis, distinguish gonorrhoea. Urethritis from other cause, so-called 
simple urethritis, supervenes at once and shows very slight dis- 
charge of very short duration. Adenitis from other infection (strain, 
muscular fatigue ?) has different association — i.e., has no discharge 
or dysuria. 

The diagnosis rests absolutely on the discovery of the gonococcus, 
which is recognized (1) by its form as a diplococcus, twin bodies with 
the straight or concave edges apposed like the halves of a grain of 
coffee ; (2) by appearance in numbers, never as a single pair ; (3) by 
their incorporation or enclosure in the protoplasm of the pus cells, as 
well as by occurrence free, i. e. , between the cells ; (4) by the affinity 
for the basic aniline dyes ; (5) by decolorization under absolute alcohol 
and under the method of Gram ; (6) by difficulty of culture, which 
really succeeds only with human blood serum. The decolorization 
by the Gram method especially differentiates the gonococcus from 



GONORRHOEA. 183 

other simulating diplococci. The gonococcus is best displayed by 
spreading a thin layer of the discharge upon an object glass, which is 
then drawn through the flame of an alcohol lamp to fix the object, 
dipped for two minutes in the solution of methylene blue (Loffler), 
washed with distilled water, well dried with blotting paper and exam- 
ined with the oil immersion, whereby the oil may be dropped directly 
upon the object. The gonococci are thus colored deep blue, the nuclei 
lighter blue, the cell protoplasm gray-blue (Finger). The micro-or- 
ganism has been thus demonstrated in endometritis, conjunctivitis, 
and all kinds of gonorrheal processes. It is scarce and often absent 
in old chronic discharge. Sexual intercourse is prohibited so long as 
it is present even in the single, so-called "bonjour" drop or sticky 
mucus seen in the morning. 

The gonococcus may now be relied upon as furnishing the very 
strongest corroborative evidence in cases of rape, 
etc., though Nissen claims to have found a simi- /} ^/°^ 

lar structure in the eves of a child born with mem- %' ' f\ 

branes intact. C;" w ^»,;^ 

The diagnosis of posterior urethritis, in the **"*$$v$* 

absence of history of gonorrhoea, is usually led up '" '-'S^jC 

to on the basis of signs of infection not otherwise ^*3oJrt> 

explicable, and rests chiefly upon examination of ^h s4j± 

the urine, which • must be always made in every s r x C\£ o 

case of dysuria. The urine (morning) in these FlG 126 _ Non . sp e C iflc 
cases shows fine, long filaments of mucus floating bacteria, streptococcus 
in its mass and sinking to the bottom of the ves- and staphylococcus, found 
sel. These clap fibres or threads (Tripper fciden) 
come from the prostate gland and its vicinity, and are very charac- 
teristic. The first and last parts of the morning urine should be 
caught in separate vessels, that it may be determined whether the 
threads come first from the urethra or later from the bladder. 

The swollen prostate may be felt with the finger as a tumid, tender 
mass protruding into the rectum, or offering obstacle to the passage 
of the catheter, which should not be introduced until all acute inflam- 
mation shall have subsided. 

Treatment. — During the stage of acute urethritis the treatment 
should be simply expectant. The testicles should be suspended in a 
light bandage, the bowels should be kept open with a saline laxative 
— Rochelle salts, Carlsbad salts — and fluids (water, milk, lemonade, 
flaxseed tea, etc. ) should be drunk freely ; every form of alcohol 
must be abjured. The diet should be light. The patient should take 
every opportunity to rest recumbent. Sexual indulgence should 
cease entirely. Priapism may be prevented at night by sponging of 
the organ from a basin of cold water at the bedside, and excitement 



184 



GONORRHOEA. 



allayed by a dose of the bromide of sodium or potassium, gr. xxx.-l. 
in a full glass of water at bedtime; or by camphor gr. iij.-v., or 
lupulin gr. iij., or both together, every two or three hours during the 
day. 

The pain of micturition may be relieved by salol, gr. v.-x. every 
two or three hours, or by the salicylate of soda, bicarbonate of soda, 
aa gr. x.-xv. every two or three hours during the day. Phenacetin, 
gr. v.-x. every four hours, has also a soothing effect. More severe 
pain with priapism, or dysuria with frequent desire of micturition, 




Fie. 127.— 1, hexagonal plates of cystin ; 2, gonorrhoeal thread composed of pus and desqua- 
mated epithelial cells ; 3, spermatozoids. 



calls for opium, gr. i, with cocoa butter in suppository, or with ex- 
tract of belladonna gr. -J-J. No attempt should be made at any 
direct medication of the urethra at this time. Upon subsidence of 
the most acute stage the urethra may be addressed at first internally 
through the urine with the oil of copaiba or sandal wood, best in the 
form of capsules, each gtt. v., of which one may be administered 
every two to four hours. Hereupon, or later when all acute inflam- 
mation shall have entirely disappeared, but not until then, the urethra 
may be medicated directly with weak injections, as of plumbi acetatis 
gr. ss.-ij. to § i-? or zinci acetatis gr. i.- § i., or argenti nitratis gr. i.-ij. 



GONORRHOEA. 185 

to | iv. aquee destillatse, at first twice a day. Alumnol in the one- to 
two-per-cent solution is a bland, mild remedy ; the chloride of zinc, 
gr. i.-ij. to the ounce, is a much more powerful antimycotic and 
styptic. Injections must be continued for several days or a week, 
at least once a day, after all sign of discharge has disappeared. 

Posterior urethritis wi]l not be reached by any ordinary syringe. 
The remedy, to be effective, must be introduced with a catheter, 
preferably with the Ultzmann capillary injector, which reaches 
only to the bulb and prostatic portion. By far the best remedy in 
these cases is the nitrate of silver, whose strength may be gradually 
increased from 1 : 500 to solutions of one, two, up to five per cent, 
prepared always, of course, with distilled water, and used in gradu- 
ally increasing quantities, at first daily, later once or twice a week. 
Toxic headaches of extreme severity, defiant neuralgias, obstinate 
anorexias, fits of depression bordering on melancholy, often yield 
like magic to this method of treatment, which in a short time con- 
stringes the prostatic urethra, prevents the absorption of septic 
matter, and literally gives new tone and zest to life. Precaution 
must be taken to boil the instrument thoroughly before each intro- 
duction, to anoint it with glycerin, and to have the solution warm. 
Excessive sensitiveness of the urethra may sometimes be quickly al- 
layed by the passage of cold water through the psychrophore for a 
few minutes once a day. 

Cystitis is best treated by washing out the bladder with weak 
solutions of boric acid and later of nitrate of silver. Treatment must 
be continued for months. Refractory cases call for use of the endo- 
scope. 

Here, more than anywhere, is to be emphasized a maxim of Hip- 
pocrates : " Primum non nocere!" Here, as much as anywhere, 
some of the finest triumphs of medicine have been achieved. 



OHAPTEE V. 

INFECTIOUS DISEASES— Continued. 

MUMPS. 

Mumps (Danish, Mompen, whence our word mum, mumble) ; 
parotitis epidemica ; French, oreillons ; German, Schafskopf, 
Ziegenpeter. — An acute, contagious infection, of short duration and 
little gravity, distinguished by painful inflammation of the parotid 
gland and vicinity, sometimes also by orchitis. 

History. — Mumps was known from the remotest antiquity. 
Hippocrates mentions it, and the older physicians associated it with 
measles, scarlet fever, whooping cough, etc. , as an affection of child- 
hood. It was observed then, as frequently since, that the disease 
prevails in epidemic form, and that epidemics are wont to precede or 
follow outbreaks of some of the exanthemata or other affection of 
childhood. 

Metastatic Mumps. — A special affection or infection of the 
parotid gland, which occurs at any age, in the course of, or a sequel 
to, many of the graver infections — septicaemia, the typhus fevers, 
puerperal fever, etc. — is set apart and distinguished from the epi- 
demic parotitis as a metastatic inflammation. A sub-variety of this 
form may follow intestinal or pelvic lesions. Canstatt speaks of 
metastasis of mumps to the pancreas in the same sense as to the 
testes, ovaries, and mammas. Schmackpfeffer reported a case 
wherein an autopsy revealed a pancreatitis in explanation of a paro- 
titis, and, after a full review of this subject, Friedrich is not willing 
to dismiss the possibility of such metastasis, a question which must 
be decided in some future extensive epidemic of mumps or fortunate 
opportunity at autopsies. A so-called reflex parotitis is sometimes 
observed after catheterization of the urethra. Baginsky reported 
three cases which occurred in his own practice after operations for 
the relief of genital affections in women. 

Etiology. — Parotitis epidemica, our common mumps, prefers the 
colder seasons of the year. Of one hundred and seventeen epidemics 
tabulated by Hirsch fifty-one occurred in winter, and of ninety -nina 



MUMPS. 187 

studied by Leichten stern forty-two were in the first quarter of the 
year. The disease shows also a preference for certain localities, in 
which it may prevail continuously, or recur with every accumula- 
tion of fresh material. Great variation is shown also in its extent or 
range. It remains confined to certain institutions, boarding schools, 
orphan asylums, barracks, etc., or again extends over, or is circum- 
scribed to, a certain quarter of a city, or ranges over the entire city 
and surrounding country. Epidemics may be extinguished in the 
course of a few weeks, or prevail throughout the greater part of a 
year. The disease shows some predilection for soldiers, probably on 
account of close association in barrack life. Some of the best reports 
are furnished by the military surgeons (Bruns). It attacks males 
always more frequently than females, and is at times limited to 
children ; or, again, spares no individual unprotected by previous 
attack, except sucklings and old people, who almost universally 
escape. The age of preference is from two to ten. In a house full 
of children mumps usually begins with the youngest, successively 
seizes the older children, and may afterward attack adults. Liabil- 
ity of males is nearly universal. The disease has often been known 
to attack ninety per cent of the residents or inhabitants of public in- 
stitutions, schools, barracks, etc. 

Mumps is undoubtedly contagious, and probably, as no other ex- 
planation seems possible, through matter expectorated from the 
mouth to contaminate the atmosphere in the vicinity of the patient. 
It may attack animals (dogs) with active salivary glands. Roth de- 
clares that third parties may carry the disease. 

Mumps is probably at first an entirely local process. From the 
nature of the disease there can be little doubt that the cause is a micro- 
organism which infects the blood, or which, from its nidus in the 
parotid gland, evolves toxines to produce fever and the other general 
symptoms of the disease. The evidence actually in possession goes 
to show that mumps originates in the mouth, and not in the blood : 
that the poison of the disease is conveyed to the parotid gland through 
the duct of Steno, and not through the blood vessels. This fact seems 
to have been proven of metastatic parotitis, where a priori reason- 
ing would certainly derive the poison from the blood. What lends 
special support to this view in epidemic parotitis is the fact that the 
disease is found associated almost universally with stomatitis or 
some form of sore mouth or sore throat. Soltmann attributes the 
exemption from mumps of infancy and old age to the fact that the 
duct of Steno is too small in infancy and too atrophied in age to per- 
mit the entrance of noxious matter. One attack secures future im- 
munity as a rule. 

The period of incubation ranges from ten to fourteen days. It 



188 MUMPS. 






may be as short as seven or as long as twenty-one days. English 
writers generally put it at a fortnight. 

Symptoms. — The disease sets in with chill or shivering fits, fol- 
lowed by fever of 102° to 105°, and may often be preceded for a few 
days by malaise, anorexia, headache, and neuralgic pains. Coinci- 
dent with the elevation of temperature is the pain, the localization of 
which distinguishes the disease. Shoots and stabs of pain are felt 
at the angle of the jaw, radiating to the temple and the ear. The 
parotid gland sivells. It fills up the space between the mastoid pro- 
cess and the angle of the jaw, mounting over the side of the face, 
and extending over the cheek and down the neck with such a degree 
of tumefaction as at times to obliterate natural outlines. By this time 
there is such interference with the action of muscles and the excur- 
sions of the jaw as to close it, so that often the handle of a spoon 
may not be inserted between the teeth. The pain, on account of the 
tumefaction, tension, and interference with the circulation, always 
severe, is sometimes excruciating, and is of course greatly aggra- 
vated by every attempt at motion of the jaw and deglutition, or 
even at times by the sight or odor of food, which may stimulate 
the salivary glands. The inflammation extends also through all 
the tissues of the throat, and is manifest often in the throat and 
mouth by marked redness and swelling, sometimes by actual dis- 
placement or partial occlusion of the palate, pharynx, and larynx. 
The lobe of the ear is lifted and carried forward; the whole head 
may be pushed over to one side. The swelling reaches its height, as 
a rule, by the fourth day, when with the fall of temperature it begins 
to subside, and subsides so rapidly as to have almost entirely disap- 
peared by the sixth to the eighth day, unless, which is not infre- 
quently the case, the opposite side takes on the same swelling to 
repeat the same process. Much more rarely the affection is bilateral 
from the start. In such a case deformity is most pronounced. The 
cheeks, the jaws, the neck form a vast tumefied, oedematous, indu- 
rated mass, and the suffering from distention becomes correspond- 
ingly great. A peculiar characteristic, and not the less striking be- 
cause somewhat comical picture, is thus presented by an individual 
affected with mumps. 

The contagious principle or cause of mumps finds nidus also, in 
certain cases, in the other salivary glands, and in an organ as remote 
as the testicle. 

The inflammation or infection of the testicle is the most inte- 
resting complication of mumps. The organ is usually affected after 
the process in the parotid has subsided, sometimes coincidently, still 
more rarely alone as the sole sign of the infection. It is the tes- 
ticle itself which is invaded — orchitis — very rarely the epididymus 



MUMPS. 189 

or the cord, and only after puberty. In double mumps the right 
testicle, in single the organ on the side of the affected parotid, is 
most frequently affected. Double orchitis is rare. Affection of the 
testicle is revealed by a sensation of weight and pain in the gland 
and along the cord, by fever, and sometimes by vomiting. The tes- 
ticle soon becomes swollen and tender, and the scrotum is often 
reddened and (edematous. 

Liability is not increased by the severity of the mumps. Orchitis 
may occur in the lightest cases. Urethritis with blennorrhoea has 
been also noticed with oedema of the scrotum, and in women, very 
exceptionally, oophoritis with leucorrhcea and swelling of the exter- 
nal labia and the mammary glands. 

Mumps, though considered a light infection, is liable to certain 
grave complications. Sudden deafness may set in from labyrinth- 
ine disease, and serious affection of the brain ensue from interfe- 
rence with the circulation- or poisoning by toxines. Mental aliena- 
tion, mania, and melancholia have been reported in consequence of 
mumps. 

Other complications recorded are hypersemia of the brain from 
pressure on the jugulars, meningitis, amblyopia and color blindness, 
conjunctivitis, laryngeal stenosis, albuminuria, hsematuria, nephritis, 
etc. But it must not be inferred that mumps is a grave disease. 
The author, in the practice of a quarter of a century, has never seen 
any other complication than a trivial and transitory orchitis. 

The diagnosis is usually easy, and is helped, in any doubt, by the 
existence of the disease elsewhere. The extraordinary swelling and 
pain, with closure of the mouth, lifting of the lobe of the ear, and 
torsion of the head, distinguish the affection. Lesser swelling with 
less pain may necessitate inspection of the throat in elimination of 
scarlet fever, diphtheria, or quinsy. Digital examination would de- 
tect a retropharyngeal abscess, which might extend to involve the 
connective tissue about the jaw. A lymphangitis, or simple adeno- 
pathy from infection of the throat— a very common affection — may be 
nearly as extensive and painful as mumps. It is usually seated or 
arises lower on the neck, has no definite duration, and is much more 
prone to suppuration. Resolution almost never occurs in metastatic 
parotitis, and suppuration shows itself in the course of a few days. 

Mumps requires but little treatment. Confinement to the house, 
if not to bed, applies of course to every case attended with fever. 
Light diet from necessity, thin milk, soups, soft-boiled egg, custard, 
suffices to secure nourishment without strain upon the inflamed 
tissue or disturbance of the stomach. Hot emollient applications — 
hot oils, olive oil, cod-liver oil, cocoa butter, vaseline, etc. ; flannels 
wrung out of hot water; hot, not too heavy, poultices of flaxseed or 



190 MEASLES. 

slippery elm ; the lead and opium wash bound on with oiled silk, best 
relieve the tension and pain. Gargles of hot water with salt, re- 
peated every half -hour or hour, are poultices applied nearer to the 
seat of the disease. A saline laxative, a dose of calomel, an anti- 
pyretic, quinine gr. ij.-v., phenacetin gr. iij.-x., broken doses of 
Dover's powder gr. ij.-iij.. every two to six hours, best meet the 
indications and protect the patient during the short duration of the 
disease. Some mode of light suspension, especially in the recumbent 
posture, gives great relief to a developing orchitis. Faradization 
later will often prevent atrophy. Affections of the ear and brain 
call for special treatment, though little hope may be harbored of re- 
lief of a deafness which sets in over night. 

Metastatic parotitis is treated in the same way, with address to 
the remote origin of the complication and speedy evacuation of 
accumulated pus. 

MEASLES. 

Measles (Sanscrit, masura ; German, Maseru) spots ; rubeola 
(Sauvages), ruber (French, rougeole, red); morbilli (diminutive of 
morbus). — An intensely contagious, acute infection, characterized by 
coryza and bronchitis, a red-spotted eruption with branny desquama- 
tion, fever of typical course subsiding at efflorescence, with liability, 
mostty as sequel, to catarrhal pneumonia, sometimes to tuberculosis. 

Synonyms and History. — Though existent from time immemo- 
rial, measles was first described by Rhazes, 900 A.D., in an attempt to 
separate it from small-pox. Rhazes noticed among the symptoms of 
measles " redness of the eyes with a great flow of tears, nausea, and 
anxiety/ 7 remarking also that the measles " that are green or violet 
colored are of a bad kind, especially if they sink in suddenly, for then 
a swooning will come on and the patient will soon die." The dis- 
ease was described under the name hhasbah. Nearly all subsequent 
writers adopted the Italian term morbilli up to the middle of the 
eighteenth century, when Sauvages substituted for it or re-established 
the term rubeola, which the French accepted in their own equivalent 
of rougeole. Rubeola means something definite. It expresses a 
characteristic feature of the disease, in fact the most characteristic 
feature — the redness of the eruption. It is unfortunate that this term 
rubeola has been adopted by certain German writers to express that 
particular sub- variety, special or hybrid form of the disease known as 
German or French measles ; popularly, in Germany, as rotheln. So 
long as scarlatina would seem by universal acceptance to be the most 
appropriate name for scarlet fever, rubeola must be the most appro- 
priate for measles. 

Foreest (1565), the Dutch Hippocrates, first pointed out certain 



MEASLES. 101 

distinctions between measles and scarlet fever, though the separation 
of the affections is usually credited to Sydenham, the English Hippo- 
crates. 

General Remarks. — The primeval home of measles is unknown. 
From its earliest recognition it has prevailed in epidemic form in 
Asia, Europe, and South America. It was imported to the United 
States with the first settlers, to gradually spread over it with the 
march of the pioneers. It reached Oregon in 1829, California and 
Hudson's Bay in 1816, the Sandwich Islands in 1818, whence it was 
carried to Australia in 1851 and to Greenland in 1861. Though the 
disease has now become indigenous everywhere, and individual 
cases are of continual occurrence in large cities, measles usually 
prevails as an epidemic over a wide extent of country, with inter- 
vening periods of absence. Epidemics die out in two to three months 
from lack of material. Measles does not hold over in sporadic cases, 
like scarlatina, but disappears completely, to reappear with reaccu- 
mulation of material every three or four years. 

Etiology. — Susceptibility to the disease is almost universal, so 
that it has been said if measles had the mortality of scarlet fever the 
human race would have long since become extinct. The eminent 
contagiousness of the disease is shown in the attack of whole com- 
munities previously entirely or for a long time exempt, as in the 
Faroe Islands, where six thousand people were seized at once. In 
1886 the disease overran nearly the whole of Russia. Thus measles 
makes up for its mildness by its range. 

Measles prevails more distinctly in the colder months. Of the 
epidemics tabulated by Hirsch, three hundred and thirty-nine occurred 
in the colder and one hundred and ninety-one in the warmer months. 
The frequency of epidemics in winter has usually been ascribed to 
the closer contact of people at this season. It is certainly observed 
in cities that the disease assumes epidemic proportions with the open- 
ing of schools and kindergartens. These institutions disseminate the 
disease because measles is a children's disease, and a children's dis- 
ease because it attacks at the earliest exposure. Escape in child- 
hood by no means secures exemption, as is evidenced by the attack 
of people of all ages in isolated regions. 

Measles occurs at all ages, preferably from one to five, the period 
of earliest exposure ; rarely among sucklings, the age of least expo- 
sure, as well as of protection by protective elements in the mother's 
milk. It is certain that even pregnancy is no defence. The organ- 
ism of measles may be conveyed by third parties and by things (fo- 
mites). 

Measles may certainly coexist with other infections, with scarlet 
fever, with rotheln, with typhoid fever, etc., and most especially 



192 MEASLES. 

and frequently with pertussis. An unmistakable coincidence is men- 
tioned by Panum, who vaccinated a child in the incubative stage 
of the disease, both vaccinia and measles running a typical course. 
With the exception of pertussis, the existence of an acute disease, 
as a rule, postpones an attack of measles until after its subsidence. 
Coincidence is therefore an exception to the rule. 

The micro-organism of measles escapes from the body through 
the nasal mucus, which, dried and infinitely subdivided, floats in 
and contaminates the atmosphere about — that is, in the vicinity of — 
the patient. Mayr certainly succeeded in propagating the disease 
with mucus from the nose. Canon and Pielicke found in the blood 
during life in fourteen cases, and in the nasal mucus, a bacillus of 
great difference of length, usually in groups or clusters, during the 
whole course of the disease. It was demonstrated by a stain of eosin- 
methylene-blue (concentrated aqueous solution of methylene blue, 
eighty ; one-fourth per cent eosin solution [in seventy-per-cent alco- 
hol], twenty; two to three hours' stain in the incubator). Doehle 
depicts protozoa as the cause of the disease. 

The period of incubation, as determined by inoculation experi- 
ments and observations by conveyance of single cases to isolated 
places, is quite definitely established at ten days — that is, fourteen 
days before the eruption. The most indisputable observations were 
furnished by Panum in the Faroe Islands. It was easy in these 
cases to trace up the source of infection, which corresponded to the 
landing of a case from a ship. In all these cases thirteen to four- 
teen days elapsed from the day of exposure to the beginning of the 
eruption. 

Symptoms. — The period of incubation is, in the vast majority of 
cases, wholly free of symptoms. Very exceptional cases show malaise 
or ephemeral fever, which may arise from toxines. The stage of in- 
vasion may be marked by a distinct chill, or, more commonly, by a 
series of shiverings, to be attended or followed by a rise in tempera- 
ture to 100° to 104°, with gastric irritation and nervous symptoms 
in correspondence with the temperature. The fever is in many cases 
so slight as to be overlooked, when the disease may- announce itself 
with more distinctive signs. After the first remission the tempera- 
ture again rises with the appearance of the eruption, to reach its 
acme at the period of full efflorescence, and to decline as it fades 
away. In an average case the fever falls by crisis — that is, within 
thirty-six hours after the first decisive fall. During the stage of in- 
vasion characteristic catarrhal symptoms show themselves in the 
mucous membrane of the nose, eyes, throat, and bronchial tubes. 
These symptoms are summed under the term coryza. The eyes 
grow intolerant to light ; the conjunctiva is hyperaemic ; the nose 



MEASLES. 



193 



"runs"; the eyes, nose, and throat itch and burn — sensations but 
partially relieved by more or less sneezing and cough. The uvula 
and soft palate now show dark-red spots and later diffuse redness, 
the so-called enanthem, the first appearance of the eruption. Bron- 
chitis, the result of the direct invasion of the bronchial tubes, be- 
longs to measles as definitely as the eruption. 

The eruption proper is seen first, as a rule, on the morning of the 
fourth day, exceptionally as early as the end of the third or as late as 
the fifth day. The eruption shows itself in " spots " (measles), usually 
somewhat elevated, dark-red, " raspberry" red, or tinged with blue, 
first upon the forehead and sides of the face. It distinguishes itself 
especially upon the face by coalescence and aggregation into irregu- 
lar or crescentic }3atches with in- 
tervening islets of unaffected tis- 
sue. During full efflorescence 
the face seems puffed and swollen. 
The eruption gradually spreads 
downward over the neck, chest, 
trunk, and extremities, to cover 
the whole surface by the eighth 
day. More or less confluent on 
the face and neck, it gradually 
grows more and more discrete 
over the trunk, legs, and feet. 
Reaching the lower extremities, 
it begins to fade from the face. 
Desquamation, which is absent 
in light cases, is furfuraceous as 
a rule. 

The eruption reaches its height 
in thirty- six to forty-eight hours, 
the period of efflorescence, and the height of the fever corresponds 
with its duration. So soon as the fever has reached its height it be- 
gins to fall, and falls rapidly, to terminate, as stated, by crisis within 
thirty- six to forty eight hours. This fall of the temperature with 
the appearance of the eruption is so characteristic as to enable the 
observer often to differentiate measles in cases of doubtful eruption 
from simulating maladies. There is the appearance that the body 
struggled with the disease, and finally succeeded, as the old writers 
believed, in throwing it off in an eruption. But the disease is not 
really in the eruption. The eruption is really only a toxic reflex, 
like herpes, urticaria, etc. The fact is, the fall of temperature is ob- 
served, as a rule, before the eruption has reached its full height. 
When it is on the eve of efflorescence, as if a poison had been voided 
13 



Bay of 

Disease * 3 4 5 6 


7 8 3 10 11 12 


wr ... | 








~~ 




103° 1 




102' 


nn 


101° r""TT~ - 








J — 

100" 


l- : ___: 


% _ s::: 


e\^~~~ 


gg.Jl -J SL 


_.i 


99 -1- i 


===£===e| 


w^y- 


WM 




hm 1 1 u n 1 1 


ST 


_: j: .__ 




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96° 





Fig. 128.— Temperature in simple measles. 



194 



MEASLES. 



from the blood the temperature falls rapidly. So the crisis occurs 
often within forty-eight hours after the appearance of the eruption, 
and hence measles (barring complications) is a mild disease. Hence 
measles is a little (short) disease. At the end of forty-eight hours 
after the appearance of the eruption there is in most cases no fever 
at all, and in many cases actually a subnormal temperature, at least 
in the morning. So well established is this fact in measles that the 
persistence of temperature, or the existence of an elevation of 
even one or two degrees on the third or fourth day after the appear- 
ance of the eruption, betokens a complication, which will announce 
itself with its distinctive signs in the course of a day or two. 



Day of 

Disease 



22 



VBl 2Z 



23 



ZZZ £ZZZ 



105' 



10V 



I 



1 



m 



m 



m 



m 



31 



& 



ft 



m 



98' 



Fig. 



Scarlatina, Measles. 

129.— Contrast between the fever of scarlatina and that of measles (Moore). 



Where records of temperature are faithfully kept complications are 
thus often announced before they may assume distinct proportions. 

Duration and Desquamation.— -The clinical history of an ave- 
rage uncomplicated case of measles implies thus ten to fourteen days' 
incubation, three days' invasion, three days' progress, and three days' 
decline. 

Abnormities, complications, and sequelce are of frequent occur- 
rence. The eruption or the catarrhal symptoms may either be ab- 
sent, morbilli sine catarrho, sine eruptione, though some eruption 
may be seen or found somewhere under scrutiny close enough. 
Blood poisoning in the stage of invasion may be so intense as to take 
life at the start — rubeola siderans. Haemorrhage may show itself in 
two forms. In the more frequent but less grave form a few or many 



MEASLES. 195 

of the spots become petechise. In the true hemorrhagic or black 
measles, rubeola nigra, observed only in cachectic cases and de- 
graded surroundings, free haemorrhage occurs — that is, blood flows 
from the nose, mouth, kidneys, vagina, or intestines, and vibices and 
ecchymoses appear upon the surface. 

Nervous symptoms may assume prominence. Headache is com- 
mon, and at times severe. Invasion, especially in young children, 
may be marked by delirium, coma, or convulsions. True meningitis 
is rare. Transitory albuminuria is common, but nephritis is very 
rare. Very sharp attack is ushered in by anorexia, nausea, vomit- 
ing — symptoms which may extend over the period of invasion. Paro- 
titis is very rare, but laryngismus, due at times to laryngeal enanthem, 
is not at all infrequent. The picture of laryngeal stenosis — some- 
times as the result of a true croup (diphtheria), more frequently of a 
false croup (laryngismus stridulus), sometimes as evoked by a spot 
of hypersemia on an exquisitely sensitive surface, which may be seen 
and treated under the laryngoscope — presents itself occasionally in 
the course of the disease. Noma, a gangrenous affection of the 
mouth or vulva, is an ugly complication in cachectic cases or under 
exceptionally degraded hygienic surroundings ; it is fortunately a 
rare complication, bat measles (Woronichin) is its most frequent 
cause. 

Catarrhal pneumonia is the complication most frequent and 
most feared. It is recognized by rise of temperature, frequency of 
breathing, increase of cough, dyspnoea, with the physical signs of 
this disease. Latent tuberculosis is brought to the surface by an 
attack of measles, as a rule. Hypersemia of the bronchial tubes and 
glands excites quiescent bacilli to quick and active growth, or renders 
fruitful a soil previously sterile to this disease. Above all other dis- 
eases, as stated already, measles liberates tubercle bacilli from bron- 
chial glands. This is probably the true relation of these diseases. 
The primary infection is a thing of the past. Penetration to the 
bronchial glands has been favored by coddling, by the house climate, 
by various medications, by the administration of cough mixtures, 
opiates, under the cover of which the disease has secreted itself in the 
recesses of the lungs — to wit, the bronchial glands. Measles, with its 
hyperaemia, its bronchial and pulmonary congestions, irrigates the 
soil, swells the glands, and arouses dormant or quiescent seed into 
active life. Ziemssen long ago called attention to the revelations of 
the laboratory with reference to cervical glands, in that they so often 
contain tubercle bacilli hitherto quiescent ; and the same condition 
has been revealed of the bronchial glands, which may be called nur- 
ture soils of the tubercle bacillus. 

The eruption of measles may prematurely disappear, "strike in," 



196 MEASLES. 

at any time, not as the cause but the effect of complications. This 
disappearance of the eruption with the development of a complication 
is, however, the exception, and not, as commonly believed, the rule. 
The eruption runs its course, as a rule, in spite of the complication. 
Complications are due to the nature of the poison, to the constitution 
of the individual, not, as commonly believed, to "catching cold/' the 
fear of which interferes with one of the chief means of successful 
treatment — free ventilation of the sick-room. 

The diagnosis is easy, as a rule. The prevalence of an epidemic 
or existence of other cases, escape of attack hitherto, are points in 
circumstantial evidence. Measles is differentiated from a simple 
catarrh or coryza by its higher temperature, by the enanthem on the 
second or third day, and by the exanthem on the fourth day; from 
hay fever by the period of occurrence and the history of repeated 
attacks of hay fever, as well as by the eruptions of measles; from 
simulating drug eruptions — copaiba, quinia, and the various anti- 
pyretics — by the history of the case, and the immediate supervention 
of these eruptions without previous coryza ; from roseola by the 
more uniform redness, of lighter color, more limited range but 
shorter duration, with the absence of fever, characteristic of this 
affection — if this affection may, indeed, be specialized. Papular ery- 
thema, which may coarsely resemble measles in the face, is distin- 
guished by its localizations elsewhere, upon the forearms and backs 
of the hands and feet, as well as by the absence of fever, catarrh, 
and bronchitis. 

Scarlatina, rubeola, variola, typhus are differentiated in the study 
of these affections. 

Prophylaxis is almost impossible. Sickly, debilitated, more espe- 
cially tuberculous children should be removed from infected houses. 
The liability of infection by third persons and things is by no means 
so great as in scarlatina, hence the necessity is not so imperative of 
withholding other members of the family such a length of time from 
attendance at school. 

The prognosis in general is favorable. The mortality of measles 
per se is almost nil. Death seldom or never occurs directly from the 
disease, but from complications, previous debilities, and bad sur- 
roundings. Thus, Pott found as the cause of death pneumonia and 
capillary bronchitis in twenty-one, and croup in three, of twenty-four 
cases. The mortality of the disease in hospital and tenement-house 
practice is quite different from that of private practice. It is not 
uncommon to observe a mortality of thirty per cent under bad sur- 
roundings, and the range would be still higher if it included all the 
incident cases of pneumonia and the subsequent cases of tuberculosis 
which have come to light in consequence of measles. The mortality 



t 
MEASLES. 197 

stands also in quite direct relationship to the age of a child, and 
diminishes from fifty per cent under two, to fifteen above this period. 
The ravages of the disease among savages, as among our own In- 
dians, were due wholly to lack of sanitation. 

The treatment is purely expectant and symptomatic. Full and 
free ventilation at a temperature of 70°, a night gown without under- 
wear, light but sufficient bed covers, absolute cleanliness, water and 
milk ad libitum, supply the requisites of treatment for an average 
case. 

Any case of fever above 103° is best controlled by warm baths, 
which may be gradually cooled, or by the occasional administration 
of phenacetin, gr. iij.-v., more especially in relief of associate nervous 
distress. Dover's powder, gr. ij., which is now made into a palat- 
able syrup (gr. v.-3i.), is just as good, is often better than any 
antipyretic or any other anodyne. Burning or itching of the skin is 
best relieved by warm baths with subsequent anointment with vase- 
line or cocoa butter. Photophobia calls for smoked glasses, or shad- 
ing of the eyes in the disposition of the bed or screens, rather than 
for darkening of the room — an objectionable procedure. 

A drop or two of a solution of morphia gr. iv.- § ss., or of atropia 
gr. i.— 3 i. ? allays any extreme irritation of the eyes ; smearing the 
edges of the lids with an ointment of hydrargyri oxidi flavi gr. v.- 3 ss. 
unguenti petrolati will prevent or cure blepharitis marginalis and 
keratitis. The same ointment, or simple pure vaseline or boric acid 
ointment, gr. xv.- § ss., snuffed into the nose, will generally relieve 
the sense of dryness and irritation in the nose and throat. The in- 
stillation of hot water or of a drop or two of the solution of atropia, 
gr. i.-f i., will often quiet earache. Evaporation from a piece of 
cotton saturated with chloroform, held close to the meatus, is often 
equally effective. Gastric distress and vomiting may require cracked 
ice ; sips of hot water, lime water, and milk one-third ; bismuth 
3ss.-3i., or chloral gr. ij.-v. ; rectal injections of sodium bromide 
gr. x.-xxx. to water 3 ij. , or of chloral gr. v.-x. to water 3 i. Few 
cases of vomiting from any cause will resist chloral, if its absorption 
can be secured. 

Nervous symptoms may call for sodium bromide gr. x.-xxx., 
trional gr. x , or chloral gr. v.-x. Phenacetin, gr. v.-x., may suffice 
for a lighter case. Haemorrhage and prostration demand alcohol — best 
in the form of brandy — black coffee, turpentine gtt. v.-xv. briskly 
stirred in a wineglass of milk ; or nitroglycerin, one per cent, gtt. i. 
in whiskey and water ; possibly opium, best in the form of the cam- 
phorated tincture, gtt. v.-xl. ; codeia, gr. ^-J, may substitute mor- 
phia for more protracted use ; carbonate of ammonia grs. v.-x. in 
milk ; ergotin, preferably sclerotinic acid, one-fourth to one-half a 



1 98 RUBELLA. 

syringeful. The syrup or wine of ipecac, to which may be added, if* 
necessary, a small quantity of Dover's powder, preferably in the 
form of a syrup, suffices to restrain any excess of cough. The 
following is a good prescription for a child : 

B Apomorphinse hydrochloratis gt. ss. 

Acidi hydrochlorici diluti gtt. x. 

Syrupi § ss. 

Aquas menthse piperitse 3 iss. 

M. S. Teaspoonful every two or three hours. 

Diarrhoea requires at first no control. Later, as the discharges 
become more abundant or colliquative, it may be restrained by bis- 
muth, to which may be added, if necessary, a drop or two of tincture 
of opium. An improvement on a time-honored remedy may be 
written as follows : 

B Tincturae opii gtt. xl - 3 i. 

Acidi hydrochlorici diluti gtt . xl. 

Aquae camphorse ad % iv. 

M. S. A tea- to a dessertspoonful every two to four hours. 

Broncho-pneumonia calls for stimulation of the respiratory 
centres as well as of the heart. These centres are best reached by 
baths, warm baths, with cold affusions to the head. A rapid respira- 
tion, a quick pulse, cold surface, somnolence, and delirium call for 
baths and baths, repeated baths with cold affusions, together with 
the use of the analeptics, camphor, benzoic acid, ether, musk, nitro- 
glycerin, caffeine, and brandy. 

Gangrene of the skin, noma, ulcerative processes, caries of bone, 
are best treated with caustics, carbolic acid, solutions of corrosive 
sublimate, or the actual cautery, later with iodoform. In all these 
cases alcohol must be administered abundantly. 

Cod-liver oil, pure or with malt extract, iron, arsenic, out-door 
air, fresh air, for the inlander especially sea-side and mountain air, 
with good food, are the best reconstructives during and after conva- 
lescence. 

RUBELLA. 

Rubella (dim. of rubeola, from ruber, red) ; rotheln (dim. of Roth, 
red) ; German measles, French measles, because described by Ger- 
man and French observers, really first isolated by an English phy- 
sician ; hybrid measles, false measles, etc. — A specific, feebly conta- 
gious, acute infection of short duration, characterized by the absence 
of prodromata, the presence of an eruption simulating that of true 
measles, faucial catarrh, and enlargement of the lymphatic glands. 

The word rubella, first suggested by Yeale (1866), soon met with 
general acceptance. The universal use of the term varicella, which 



RUBELLA. 199 

has a similar relation to variola, establishes a perfect precedent for 
rubella and rubeola. 

History and Nature. — Bergen (1752), who described it among 
the roseola?, first maintained the view that it should be separated 
from measles and scarlet fever ; but it was reserved for an English 
physician, Maton (1815), to establish the individuality of the disease, 
as based chiefly upon the observation that though self -protective, in 
that one attack confers future immunity, it does not protect against 
either measles or scarlatina, nor do these diseases protect against 
rubella. 

Rubella stands in relation to rubeola, not as varioloid, but as vari- 
cella to variola. It certainly differs from both measles and scarlet 
fever in its contagiousness, mode of invasion, symptomatology, du- 
ration, and decline. Though much less contagious than measles, and 
hence much less frequent, the disease is decidedly more prevalent 
than is commonly believed. Many cases are mistaken for measles, 
and most of the so-called successive or repeated attacks of measles 
are really rubella?. 

Etiology. — The disease is propagated by contact, also by third 
persons and by things. The bedding of steerage passengers has been 
known to conceal and convey contagion for a long time. From the 
nature of the disease the cause of rubella must be a micro-organism, 
but the specific structure has not yet been isolated. Micrococci have 
been observed in the blood, but without any other evidence of posi- 
tive relationship. Griffiths found a highly toxic ptomaine in the 
urine peculiar to rubella. 

Rubella occurs at all ages, rarely in infancy ; seventy-five per 
cent of cases before fifteen, the period of greatest liability. But sus- 
ceptibility to it is so much less than to measles that the majority of 
people escape it throughout life. Attack in adult life is much more 
frequent than attacks of measles, first, because the susceptibility is 
not so universal, so that childhood bften escapes it ; and, secondly, 
because epidemics prevail at much longer intervals. Adults have, 
however, immunity in high degree. Kassowitz observed but five 
cases in adult life. Seitz recorded a case in a woman aged seventy- 
three. 

Symptoms. — The period of incubation, two to three weeks, is 
uncommonly long, while the stage of invasion, or prodromal stage, 
one-half to one day, is uncommonly short. An initial chill is an ex- 
ception ; malaise, pain in the head, back, or joints, anorexia, rarely 
vertigo, very rarely more pronounced distress on the part of the ner- 
vous system, more or less immediately usher in the eruption and 
affection of the mucosa? and glands. Not infrequently the appear- 
ance of the eruption, totally unprefaced by any fever, is the first sign 



200 RUBELLA. 

of disease. The eruption appears as minute rose-red maculce, dis- 
crete or confluent, "like dark- red ink pen points in white blotting 
paper," on the forehead and temples, spreading quickly over the rest 
of the face, neck, and trunk, to reach full efflorescence and begin to 
fade in twenty-four to thirty- six hours. By the third day, as a rule, 
all signs of eruption disappear without desquamation. Coincident 
with the eruption is a rise of temperature to 99° to 101° F., very ex- 
ceptionally to 102° to 103°. 

Hypersemia of the conjunctiva with photophobia and epiphora, 
of the nasal mucous membrane with a sense of dryness and irritation, 
with sneezing or with increased discharge, more especially hyper- 
semia or visible enanthem of the fauces and pharynx, may precede 
the eruption during the stage of invasion, when it occurs, to co-exist 
with the eruption, and remain after it as late as the fourth day of 
the disease. 

Affection of the glands constitutes a much more distinctive feature 
of rubella. The cervical, submaxillary, and occipital glands, more 
rarely also the glands of the axilla, elbow, and groin, become swollen 
and tender, limiting the movements of the head at times in the 
swelling and stiffness of the neck. These adenopathies, which exist 
in fifty to seventy-five per cent of cases, disappear entirely in two or 
three days. Abnormal cases show only an eruption or only affection 
of the glands. 

As a rule, the physician is summoned to distinguish the eruption, 
which, as stated, appears earlier, often without any previous disor- 
der ; is lighter in color — a rose, not a raspberry red ; more frequently 
discrete, or, when confluent, more diffuse, not aggregated into 
patches ; disappears completely, without, or with but slight, desqua- 
mation, in one to three days. These features, in connection with the 
more pronounced implication of the throat and the glandular affec- 
tions, sufficiently distinguish the disease. 

Rubella is distinguished from measles, the only affection with 
which it is likely to be confounded, by the history or absence of a pre- 
vious attack of measles ; by the existence of other cases; by its feebler 
contagiousness, longer incubation, shorter invasion, hence earlier 
appearance of the eruption, absent or but light or limited affection of 
the mucosae, more frequent and extensive adenopathies, more trivial 
fever, and shorter duration. 

Rubella is distinguished from scarlatina by the history of the 
individual, as stated above ; by the longer incubation, two to three 
weeks in rubella, one day to one week in scarlet fever ; by the char- 
acteristic intense sore throat of scarlet fever in contrast with the triv- 
ial catarrh of rubella ; by the violence of the invasion of scarlatina ; 
vomiting, hyperpyrexia, often delirium and convulsions, in scarlet 



SCARLATINA. 201 

fever, all absent in rubella ; by the more universal affection of 
glands in rubella, more intense inflammation and tumefaction of the 
submaxillary glands only in scarlet fever ; by the appearance of the 
eruption first upon the face or universally in rubella, first on the 
chest and neck with slower spread in scarlet fever ; by the disap- 
pearance of the eruption in one to four days in rubella, in four to six 
days in scarlet fever ; by the disappearance of symptoms with ap- 
pearance of the eruption in rubella, by the persistence of symptoms 
during the eruption of scarlet fever ; by the strawberry tongue of 
scarlet fever, absent in rubella ; by the albuminuria and affections of 
the kidney in scarlet fever, absent in rubella ; by the desquamation, 
membranous in scarlet fever, absent or furf uraceous in rubella. 

The roseola, adenopathies, and sore throat of syphilis could not, 
on account of their persistence, be long mistaken for rubella, even in 
the absence of all history of a primary infection. 

The diffuse erythemata of a drug eruption, antipyretics, copaiba, 
chloral, etc. , have a history of their use, are unattended with fever, 
sore throat, or affections of the glands. 

Inasmuch as most people escape rubella, isolation of cases in a 
separate room or story of the house is, when practicable, advisable. 

The mortality is almost nil. In this regard the disease has, how- 
ever, the same history as measles. Bad surroundings may impart 
great gravity. Hospital and tenement-house practice furnishes a 
mortality of three to ten per cent, due almost wholly to complica- 
tions, chief among which are capillary bronchitis and broncho-pneu- 
monia. 

Treatment, which is for the most part superfluous, does not dif- 
fer, when necessary, from that of measles. 

SCARLATINA. 

Scarlatina ; scarlet fever ; German, Scharlach; Italian, scarlatto, 
red. — A treacherous, acute, contagious infection, characterized by a 
more or less typical fever and inflammation of the throat, a diffuse 
scarlet exanthem followed by membranous exfoliation of the skin, 
occasionally by otitis, exceptionally by arthritis, and not infre- 
quently by nephritis. 

History. — The first use of the term febris scarlatina is found in 
a comment by Lancelotti, of Italy (1527), but it was not distinctly 
applied to the affection as we know it until by Sydenham (1661), 
who first separated it from measles, with which it had hitherto been 
confounded. Sydenham saw only mild cases. He considered the 
disease " only an ailment ; we can hardly call it more," but was able 
to recognize it without the help of throat symptoms, which he does 
not mention in his brief description. It was, however, a full cen- 



202 SCARLATINA. 

tury after Sydenham before the ability to separate scarlatina became 
common property, and no sooner was it firmly set upon its tripod of 
symptoms, to wit, fever, exanthem, angina— that is, no sooner were 
the throat symptoms established as an integral factor of the disease 
— than it became confounded with diphtheria as much as it had ever 
been with measles. Irregular cases of either are not yet easily dis- 
entangled. 

Etiology. — Whence it was originally imported or when it first 
appeared in Europe is unknown, but it was first recognized in Eng- 
land in 1661, Scotland in 1716, Germany and Italy in 1717, Denmark 
in 1740 ; North America, Kingston and Boston in 1735, New York 
^ and Philadelphia in 1746, Ohio and Kentucky in 1791, Toronto in 
1843, New Orleans in 1847, California in 1851. 

The disease is rare in Asia and Africa, and is said to be (Wer- 
nich, 1871) entirely unknown in Japan. Scarlatina is therefore 
much less widely disseminated than measles and small-pox, both of 
which have repeatedly ravaged Asia and Africa. 

A pronounced peculiarity of scarlatina, in distinction from mea- 
sles and small-pox, is the variation in the intensity of epidemics, 
which are sometimes so mild, as in the time of Sydenham, that the 
affection vix nomen morbi merebatur (scarcely deserved the name 
of a disease), and again virulent and malignant, more especially in 
villages and small towns, with a mortality as great as that of chol- 
era and the plague. " Malum hoc grave," said Sennert almost sim- 
ultaneously with Sydenham, ' ' periculosum et ssepe lethale est." 
Bretonneau never saw a single fatal case of scarlet fever in all his 
practice during twenty-four years — 1799-1823 — but in 1825 he en- 
countered an epidemic so virulent as to cause him to entirely change 
his opinion regarding the benignity of the disease. Lewis Smith 
relates that a distinguished physician of New York treated more 
than fifty cases of scarlet fever in one of the hospitals, without a 
single death. A few months later his own son died of the disease. 
That this virulence is not due 'to the accumulation of susceptible 
material in long intervals of absence is proven by the experience 
of Kostlin, of Stuttgart, who observed an epidemic in 1846 so mild 
as to be without a single death, following an interval free of scar- 
latina for a period of sixteen years. 

Soil, season, climate offer no explanation of this peculiarity ; we 
remain as yet, in the language of Drake, " entirely ignorant of the 
causes or conditions which determine these remarkable diversities of 
phenomena and danger." 

Thus it may be said that since small-pox has been shorn of its 
terrors, scarlatina takes rank, next to diphtheria, as the most dreaded 
of all the infections which now prevail. It is estimated to cause one- 



SCARLATINA. 205 

twenty-fifth to one-twentieth of the whole mortality in England and 
America. 

Susceptibility to scarlatina is much less than to measles, one 
member of a large family being often alone attacked. Hence the 
majority of individuals escape it throughout life. Individual fami- 
lies seem predisposed to or exempt from the disease. Ziemssen says 
he saw cases which annihilated posterity, and practitioners every- 
where have become demoralized by the loss of one member after 
another of a family to literally extinguish it. Geil attributes suscep- 
tibility to the condition of the throat. The disease, to take hold, must 
have a denuded surface. While epidemics of scarlatina are much 
less frequent than measles, decades often intervening, individual 
cases are much more common. It is said that children have been 
born at various stages of the disease, but it must be remembered that 
hyperemia and desquamation occur frequently in the new-born in 
health. Sucklings certainly enjoy comparative immunity. The age 
of predilection ranges from two to seven. Sixty per cent of cases 
occur before the age of five, ninety per cent under ten. Attacks 
later in life are rare and are usually mild. Here too, however, are 
observed the same differences in epidemics. Thus, in Ziemssen's 
report, the mortality among adults in 1865-1875 was 11.5 per cent, 
and in 1876-1887 it was but 1.3 per cent. 

One attack confers immunity, as a rule, for life. With an obser- 
vation of two thousand cases Willan never saw a second attack. 
A second attack is possible, but rare, and occurs more especially in 
cases of exposure in more advanced life in taking care of a younger 
member of a family affected with the disease. These second attacks 
are, as a rule, so abortive or rudimentary as to be easily overlooked, 
and are recognized at times, as are first attacks in the mildest cases, 
only by sequeke. Hence the suspicion may be entertained that some 
of the insusceptibility of certain individuals may be immunities con- 
ferred by attack so mild as to have been considered ephemeral 
affections. Most so-called second attacks are erythemata, rubelke, 
septic rashes, etc. 

Pregnancy certainly protects against it, but puerperium and open 
wounds of any kind invite it. 

Regarding puerperal scarlatina, caution must be entered against 
confounding it with septicaemia, which often shows fever and erup- 
tions simulating scarlatina. There is no doubt, however, that the 
puerperal state confers additional susceptibility to scarlatina. In 
these cases the eruption occurs more quickly, almost suddenly. The 
throat symptoms are much milder or are absent altogether, while 
local lesions about the vulva and uterus predominate. 

In proof of the increased susceptibility of the puerperal state, 



204 SCARLATINA. 

Boxall declared of his cases that ten had had scarlatina before, and 
one had had it twice. 

With reference to surgical scarlatina, so-called, the same precau- 
tion must be entertained to prevent confusion with erysipelatous, 
erythematous, or other eruptions of septicaemia. 

Etiology. — The disease is conveyed by contact, direct or indirect, 
as by clothing eminently, by washing, bedding, furniture, letters, 
books (as from a library or school), toys, etc. A not infrequent 
source of infection is milk, sometimes from an infected dairy. Per- 
haps the most instructive example of this source of contagium was 
furnished by Miller, who reported twenty-four cases of infection in 
this way. 

The disease may be conveyed also by third persons, who may 
carry the poison in their hands, hair, or clothing, but may them- 
selves remain exempt. Convalescents from the disease carry it to 
school, church, theatre, train, etc., and disseminate it throughout a 
community. 

The cause of the disease is said to be disseminated from the skin 
or the secretions, and given off during incubation and desquama- 
tion, as well as during the stage of eruption. There is as yet no 
direct proof that the poison of scarlatina lies in the skin. It is sin- 
gularly tenacious, adhering to clothing after months of disuse, and 
to rooms after months of vacation and seemingly thorough disinfec- 
tion and ventilation. The poison of scarlatina literally lurks in long- 
discarded clothes. Cold does not affect it. It is destroyed, however, 
by heat, especially by steam, and quickly by steam in motion — so- 
called " live steam." Henry, after subjecting the flannel garments 
of scarlatinous patients to a dry heat of 212° F., had them worn by 
unaffected children from six to thirteen years of age, no infection 
following. 

Bacteriology. — The cause of scarlatina, presumptively a micro- 
organism, has not yet been definitely determined. Klebs (1880) pic- 
tured and described a structure found in the blood as the monas 
scarlatinosum. Eklund, Stockholm (1881), Power, Cameron and 
Klein (1885-86), Jamison and Eddington (1887), Marr (1891), all 
ascribed to various micro-organisms pathogenic properties, but all 
these various micro-organisms are now believed to be varieties of the 
ordinary pyogenic bacteria. It cannot as yet be maintained of any 
of them that they are found uniformly or only in scarlatina, nor 
that the disease produced by them is really scarlatina. It is not yet 
established that any of the lower animals are susceptible to the dis- 
ease. It would be more natural to look for the poison in the throat 
and in the blood in the earliest stage of the disease, rather than in 
the secretions from the kidneys or the substance or exfoliations of the 



SCARLATINA. 



205 



1105 Sl^" L— J 



skin. The kidney affection is doubtless the result of a chemical poi- 
son in its escape from the body, and the exanthem must also be 
regarded as toxic, like that produced 
by certain drugs. Luff has suc- 
ceeded in eliminating a hitherto un- 
known alkaloid from the urine of 
scarlatina, and Leyden declares it to 
be useless to look for the poison of 
scarlatina in the skin. 

Regarding the relation of diph- 
theria, it is admitted that one may 
follow the other, and that they may 
even coincide, but only as exceptions. 
The rule is that the diseases prevail 
in communities and exist in individ- 
uals independently of each other. 



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Fig. 131.— Protracted scarlatina. 



once developed from the angina of scarlatina a specimen of the 

bacillus of diphtheria. 

SyihjDtoms. — The period of incuba- 
tion is short, ranging from one to seven 
days. Ziemssen declares that the few 
unimpeachable observations that we pos- 
sess put it at seven days. English 
writers make it generally less, and de- 
clare that from the second day after 
exposure liability of attack grows pro- 
gressively less. 

The invasion is usually sudden and 
violent; grave, dangerous, and some- 
times fatal illness developing within a 

few hours. An initial chill or series of shiverings is attended with 




Fig. 232.— Fatal scarlatina. 



"206 SCARLATINA. 

a quick and high rise of temperature. It is more frequently the case 
that the disease is ushered in without any chill at all. A child presents 
evidence of attack in a shock, manifest by extreme pallor and prostra- 
tion. A highly susceptible, sensitive child may be seized with a con- 
vulsion. Usually the scene opens with vomiting. Early vomiting 
belongs to all the grave, acute infections. It occurs with especial fre- 
quency in scarlatina because of the gravity of the disease. After the 
vomiting it is noticed that the patient has fever. Inspection thus 
early reveals angina, or the child complains at once of sore throat. 
Vomiting, sore throat, and fever at the start should excite the sus- 
picion of scarlatina, or, in the presence of an epidemic or proximity 
of another case, establish the existence of the disease. The tempera- 
ture distinguishes itself by the rapidity of its ascent. The ascent of 
the temperature in scarlet fever is more rapid than in almost any 
other disease, reaching often within twenty-four to forty-eight hours 
104° to 107°. Calor morclax was the term applied by the older pre- 
thermometric writers to express the biting heat of the skin. The 
temperature reaches its height with the efflorescence of the eruption, 
and terminates by lysis, barring complications, in one to two weeks. 

In correspondence with the height of this fever, especially in 
young children, nervous signs, as stated, show themselves — delirium 
and convulsions. The delirium may deepen rapidly into coma. 
There is in every marked case profound prostration. It is seen on 
the most superficial inspection that the child is seriously ill. This 
stage of invasion lasts from one to two days. Comment has been 
made upon the irregularity or variety in severity of epidemics of 
scarlatina. The same variety is noticed of individual cases in the 
same epidemic. In the same family, side by side with a malignant 
case, occurs an attack so mild that it may be scarcely recognized. 
Lightly affected brothers and sisters may be playing about the house 
where one member lies fatally ill or has just fallen a victim to the 
disease. So there may be every grade of intensity in the onset, but, 
as a rule, the disease is announced by a sudden attack of fever at- 
tended by vomiting, which assumes more and more importance when 
it may not be accounted for by a sufficient provocation, as by indi- 
gestion, or by other infection, croupous pneumonia, cerebro-spinal 
meningitis, small-pox, etc. 

In the absence of these symptoms the diagnosis must be held in 
abeyance until the appearance of the eruption. The eruption shows 
itself in twelve to twenty-four hours after the initial symptom, chill 
or vomiting or shock, on the face, over the forehead, cheeks, the 
chin, and often at the same time, as a rule in fact, at the clavicles. 
Here, at least, it is first seen. When search is made it may usually 
be discovered soonest on the neck, breast, and back. It usually 



SCARLATINA. 207 

spares or skips the region of the mouth, which is left blanched by 
contracted capillaries, in striking contrast with the scarlet flush of the 
rest of the face. The ichite line about the mouth, the apparent 
bleaching of the chin, make the diagnosis easy as between this dis- 
ease and measles or small-pox. Seen at some distance the eruption 
appears uniform, but close inspection shows it punctate, with conflu- 
ent halo ; yet, though confluent, there are lines or spaces here and 
there of unaffected surface. This marbled appearance of the skin is 
very characteristic, and is due to the intense irritability of the vaso- 
motors, which show paralytic dilatations and spasmodic contractions 
in the same sets of capillaries. The deeply colored skin is bleached 
out by pressure in lines or surfaces, so that figures or letters may 
be inscribed upon the surface with a vividness equalled in no other 
disease. 

The color is scarlet, that bright red which is designated by this 
hue, in striking contrast to -the duskier red of measles. The Germans 
speak of the crushed-raspberry color of scarlatina, as distinct from the 
mulberry hue of measles. The shade becomes darker, however, in 
bad cases, or especially under defective hygiene, when it may be sub- 
stituted by hemorrhagic eruptions. In a pronounced case the af- 
fected skin is more or less cedematous. The eruption lasts from four 
to six days, extending meantime over the body, but with less uni- 
formity over the extremities, where it may show itself only in blotches 
or patches. It begins to fade in the order of its appearance, first from 
the face, neck, and chest, later over the body, and disappears with a 
desquamation or exfoliation of the skin, which constitutes one of 
the peculiar features of the disease. From regions covered by a 
thick epidermis, the hands and feet, more or less perfect casts, epi- 
dermic gloves and stockings, may be detached. More or less perfect 
specimens of this kind are to be found in the museums. The desqua- 
mation begins usually on the sixth day. It may be, in a mild case, 
furf uraceous. It may, indeed, be absent altogether, but it is usually, 
as stated, membranous or lamellar, the skin peeling off in strips and 
flakes. The process may be repeated several times during the course 
of the disease, to form at times an interesting diversion or an annoy- 
ing occupation of convalescence. It is impossible to overrate the 
value of this process of desquamation. It confirms the diagnosis in 
a doubtful case. It establishes the pre-existence of the disease. It 
reveals the nature of a meningitis, rheumatism, an ear disease, a 
nephritis, which have suddenly or insidiously developed. 

The sore throat is one of the cardinal symptoms of the disease. 
It precedes the eruption, as has been said, and constitutes at times an 
overshadowing symptom. Suspicion is excited of the existence of 
scarlatina by the fact that the child complains of the throat, and it is 



208 SCARLATINA. 

seen that there is some hesitation or difficulty with deglutition. The 
act of swallowing is marked by an expression of pain ; by the appli- 
cation of the hands to the neck ; sometimes, as a rule later in the 
course of the disease, by regurgitation of fluids through the nose. In 
many cases an inspection of the throat discloses at a glance the 
character of the disease. As a rule, the sore throat of scarlatina dif- 
fers in no way, at first, from that of a simple catarrh. There is red- 
ness, dryness, and swelling. The mucosa is puffed or glazed, espe- 
cially about the soft, palate and uvula. The glands of the neck 
become swollen and tender. Diphtheritic patches, often gangrenous 
sores, may appear later, while an extensive inter glandular cellulitis 
may swell the neck to such degree as to obliterate its natural out- 
lines. It is therefore not at all strange that scarlatina is often con- 
founded with diphtheria. It is to be remarked, however, that no 
individual symptom shows such variation of intensity as the angina. 
Throat symptoms may be so mild as to be detected only on close inspec- 
tion — scarlatina simplex or sine angina ; or so severe, as said, as to 
overshadow all other signs — scarlatina anginosa, of the older writers. 
It is now no longer an unsettled question whether the diphtheritic 
exudations which occur in grave cases belong intrinsically to scarla- 
tina or to a complicating diphtheria. The view now prevails that 
the affection is primary. It is produced by the micro-organisms of 
pus. It belongs to scarlatina, and it may, in the vast majority of 
cases, by culture be differentiated from diphtheria. 

Among the disturbances of the digestive organs common to all 
the infections, the condition of the tongue is peculiar in scarlatina. 
The tongue is coated white and studded with red spots, the protrud- 
ing swollen papilla?, to constitute what is known as the straivberry 
or mulberry tongue. While this condition is not absolutely peculiar 
to scarlatina, it occurs in it more frequently than any other infection, 
and from its obtrusiveness is regarded as a sign of much value. It 
is unfortunately not always present, but when present it should ex- 
cite at once suspicion of the existence of this disease. 

Scarlet fever shows predilection for three organs besides the skin 
and throat — namely, the ear, the joints, and the kidneys. The way 
is open to invasion of the ear from the throat through the Eustachian 
tube. So scarlatina is the most fertile source of earache, otitis media, 
and otorrhcea. The membrane of the drum is seen to be intensely 
reddened on inspection, or it may be paler and pushed outward by 
fluid pent up within the drum cavity. 

Suppurative processes may intervene, to extend to or directly in- 
volve the fold of dura mater which in the young pushes into the 
cavity of the drum. Scarlatina is thus the most frequent cause of 
an immediate or ultimate lepto-meningitis. 



SCARLATINA. 209 

Affection of the joints is much more uncommon, but there occurs 
in certain cases or certain epidemics a peculiar scarlatinal rheuma- 
tism affecting chiefly the larger joints — ankle, wrist, elbow, and knee. 
The affection runs usually a mild and short course, but may, unlike 
true rheumatism, result in suppuration or leave permanent deformity . 
The joint affection is to be referred in these cases to a mixed septic or 
secondary pyogenic infection. 

Of all the signs, complications, or sequelae connected with scarla- 
tina, no one assumes such prominence and importance as the affec- 
tion of the kidneys. Scarlatina is said to be the mother of acute 
nephritis. Aside from the transitory albuminuria which may attend 
any high fever, disease of the kidneys is comparatively frequent. 
Epidemics are distinguished from each other in this regard with en- 
tire or comparative absence and frequency of this complication. The 
severity of the individual case or of the epidemic does not necessarily 
indicate the probability of nephritis. It cannot be said that early ex- 
posure, as to cold, predisposes to it. It may not be ascribed to affec- 
tion of the skin ; small-pox, with its destructive lesions, does not show 
it. Every case marked by high temperature shows, as stated, some 
albuminuria, but the albuminuria which excites apprehension is that 
which appears, not at the height, but in the later course of the disease, 
at the end of the third week after the disease proper, during convales- 
cence. Strictly speaking, the process is, therefore, a post- scarlatinal 
nephritis. It sets in on the tenth to the thirty-first day — on the ave- 
rage in twenty days after the first show of the rash. It is an acute 
parenchymatous process, from which the patient recovers or suc- 
cumbs quickly, very rarely developing into chronic Bright's disease. 
It is announced often by nervous symptoms — headache, neural- 
gia, vertigo, insomnia, restlessness, blindness, convulsion, or coma. 
Puffiness of the eyes, any local oedema or dropsy, should excite 
suspicion of its presence. 

Scarlatinal nephritis may be divided into two periods, in the first 
of which there is a diminution in the quantity of urine, albuminuria, 
and some of the general symptoms mentioned. The second period is 
distinguished by hematuria with the discharge of formed elements, 
granular and epithelial casts, also with an increase in the quantity of 
urine and diminution of the general signs. So that should the urine 
become more abundant, contain more blood, and exhibit formed ele- 
ments, though grave symptoms may still show themselves for a 
time, the worst is over, and, as Sorensen puts it, " the kidneys are 
beginning to free themselves of the disease." Perhaps the most grave 
single symptom of nephritis is anuria, but even long-continued 
anuria is not incompatible with recovery. While it may be said that 
the gravity of the case corresponds in a general way with the degree 
14 



210 SCARLATINA. 

of oliguria or the duration of anuria, there need never be despair as 
to the possibility of recovery, as Whitelaw reported a case of recov- 
ery after a total absence of urine for twenty -five days. As a rule, 
it may be said that the blood and albumin disappear in mild cases, 
and the patient recovers from the nephritis entirely in two to three 
weeks. 

Forms. — Besides the typical form described, scarlatina shows 
itself in variation as follows : 1. Abortive, in which the eruption dis- 
appears after a short duration, without, or with very mild, throat 
symptoms, but usually with lamellar desquamation, and sometimes 
with subsequent nephritis. 2. Fulminant, in which the patient is 
killed by the poison of the disease before the period of eruption. 
3. Anginose, in which throat symptoms predominate. 4. Malig- 
nant, with the status typhosus, in which all symptoms are intense 
and haemorrhage may occur free from the various mucosae or into- 
the skin, or with rapid collapse after the signs of a cholera morbus. 
In some very exceptional instances of undoubted scarlatina the erup- 
tion is entirely wanting, throat symptoms only presenting. In these 
cases careful inspection will usually disclose some eruption on cov- 
ered parts, especially on the posterior aspect of the body. It may be 
seen at times on or over any part of the body immediately after death 
from fulminant forms. 

True diphtheria may coincide with or follow scarlatina ; much 
more frequently the membrane which forms in the throat is sui 
generis. The membranous angina or pseudo- diphtheria of scarlatina 
is much less amenable to treatment than true diphtheria. 

The diagnosis rests upon : 1. The absence of previous attack. 
2. The existence of other cases. 3. The short period of incubation — 
one to seven days as a rule. 4. The violence of the invasion, espe- 
cially the occurrence of unprovoked vomiting (eighty per cent of 
cases), and the nervous symptoms. 5. The early appearance (sec- 
ond day) of the eruption, which shows itself first usually about the 
clavicles, is scarlet-colored, diffuse, but punctate upon close inspec- 
tion ; in its disposition about the face commonly sparing the mouth, 
showing in vivid contrast the blanched lips and the blazing cheeks. 
6. The strawberry tongue. 7. The early appearance of throat 
symptoms with glandular enlargements in the neck. 8. The lamel- 
lar desquamation. 9. The ear complications. 10. Nephritis. 

In very mild, sporadic, or anomalous cases the diagnosis may be 
determined only by desquamation, complications, or sequelae. 

Scarlatina is differentiated from measles by knowledge of pre- 
vious attacks of either, existence of other cases of either, especially 
in the same family, neighborhood, or school ; by the longer incuba- 
tion of measles, when the period of exposure may be (exceptionally) 



SCARLATINA. 211 

known ; by the coryza which precedes the eruption of measles, and 
the angina that of scarlatina ; by the shorter or more intense inva- 
sion of scarlatina with vomiting, and sharp nervous symptoms not 
so common in measles ; by the time of appearance of the eruption 
(twenty-four to forty-eight hours after initial chill or vomiting in 
scarlatina, four days in measles) ; by the color, character, disposi- 
tion, and duration of the eruption (dark red, aggregated in patches, 
and disappearing in two to four days in measles ; scarlet-colored, 
punctate, diffuse over the chest and face, sparing the mouth, disap- 
pearing in eight days plus in scarlatina); by the complications or 
sequelae (bronchitis, catarrhal pneumonia, in measles ; joint and ear 
affections, nephritis, in scarlatina) ; by the desquamation (usually 
branny in measles, membranous in scarlatina). 

Scarlatina is differentiated from rubella (rotheln) by the longer 
incubation or shorter or absent stage of invasion ; by the darker col- 
ored and shorter duration of the eruption of rubella ; by the as- 
sociate catarrh of the nose and eyes in rubella, absent in scarlatina ; 
by the much more severe faucial. inflammation and gland implica- 
tion in scarlatina ; by the much milder character and shorter dura- 
tion of rubella. 

Septicaemia and pyaemia show, with the history of a cause, suc- 
cessive chills, irregular temperatures, efflorescences, quite different 
in appearance and order of distribution from the eruption of scar- 
latina ; more marked enlargement of the liver and spleen ; more 
common general affections, metastatic processes, longer duration. 
Erythema, a diffuse, rather dark redness, without points or des- 
quamation, though sometimes with a light furfuraceous desquama- 
tion, with absent or but very slight fever up to 100° F., has neither 
the throat symptoms nor complications of scarlatina, and disappears 
in a few days. Drug eruptions — copaiba, cubebs, antipyretics — have 
a history of administration, no fever, no complications. 

Scarlatina differs from diphtheria in its cause. It may be de- 
clared that the cause of diphtheria has been now definitely deter- 
mined. While the same cause is not to be found in unmistakable 
cases of scarlatina, it must be held in mind that the diseases may, 
as stated, coincide, and that either may be a sequel to the other. 
These things, however, are exceptional ; the rule is that the diseases 
exist alone, and that, as stated, the exudation of scarlatina is not 
that of diphtheria, but is sui generis. 

Clinically the affections differ as follows : The false membrane 
appears at once in diphtheria, later in the course, three to five days, 
of scarlatina. It shows itself in nearly all cases of diphtheria, but in 
only severe cases of scarlatina — namely, such as are marked by high 
fever, delirium, etc., at the start. It shows a preference, after the 



212 SCARLATINA. 

pharynx, for the larynx in diphtheria, and for the upper respiratory 
passages in scarlatina. In connection with it suppuration of the 
cervical glands and affections of the ear are frequent in scarlatina, 
rare in diphtheria. The interglandular connective tissue is in- 
durated in scarlatina, and only cedematous in diphtheria. Paralysis, 
which is frequent in or after diphtheria, is almost unknown in scar- 
latina. On the other hand, nephritis, a frequent sequel of scarla- 
tina, is very rare after diphtheria. Lastly, as stated, treatment has 
much less effect on the membrane of scarlatina. For all these 
reasons it is proposed by good clinicians to abandon the use of the 
term " diphtheritic" in scarlet fever, and to designate such cases as 
*>" membranous scarlatinal anginas." 

Besides the affections of the organs mentioned, grave complication 
is not infrequently presented by the intense inflammation about the 
neck. The glands, the lymph vessels, the interglandular tissues are 
swollen and amalgamated into a mass of board-like induration, 
which fixes the head to the body, compresses the great vessels, and 
results not infrequently in extensive suppurations. Phlegmonous 
processes, gangrenous destructions, occur frequently in connection 
with diphtheritic or pseudo- diphtheritic deposits in the throat. The 
pressure may compress the trachea or suffocate by oedema of the glot- 
tis. Pus may burrow down into the chest, to erode in its course 
large vessels and to lead to fatal haemorrhage or destroy important 
nerves or other structure. The inflammation of the throat may ex- 
tend to involve the larynx and bronchial tubes. Pneumonia, both 
bronchial and croupous, occurs not infrequently in grave cases. 
Haemorrhage of the lungs, gangrene, more especially oedema, hy- 
postases, take life directly or indirectly by overstrain of the heart. 

The most frequent and fatal so-called end or terminal complica- 
tions are the affections of the serous membranes. Meningitis heads 
the list, in that it is not only the most severe but most early mem- 
brane involved. It occurs at times almost with the onset of the dis- 
ease, so that the separation of this affection from toxic effects of the 
blood poison upon the brain itself may be difficult. In meningitis 
the headache becomes more intense, or recurs if it shall have sub- 
sided. The special senses suffer extreme hyperesthesia. There is 
usually evidence of affection of the membranes of the spine, opistho- 
tonos, vomiting, convulsions. The pleura is next most frequently 
affected. Scarlatinal pleuritis distinguishes itself, strange to say, 
by its unilateral* character, and differs from pleuritis from other 
causes in the fact that it so easily becomes purulent. Pericarditis 
is usually so much more rare as to be generally overlooked, while 
endocarditis is readily recognized by its valve lesions, hypertro- 
phies, and embolic products. 



SCARLATINA. 213 

All these various complications are now known to be due to the 
micro-organisms of pus, which, strictly speaking, have nothing 
really to do with the cause of scarlatina. The cause of scarlatina 
opens the way for their invasion, and these micro-organisms, or the 
evidence of their invasion, have been traced directly from the throat 
as the avenue of entrance. 

The prognosis of scarlatina varies greatly, perhaps as in no 
other disease. On account, however, of the severity of certain epi- 
demics, and of the suddenness with which the disease may assume 
gravity* in any individual case by reason of its own poison or by 
reason of complications, the prognosis is always grave. Reimer, 
who studied the subject from this standpoint most thoroughly, says 
that the prognosis of a simple complicated case which has no mortal- 
ity advances through the complicated cases of medium gravity with 
a mortality of 25 per cent up to the severest cases whose mortality 
reaches 83.75 per cent. 

In estimating the prognosis it may be said that the pulse, as a 
rule, corresponds to the temperature. Arhythmia is usually a fore- 
runner of complications. Grave nervous symptoms are always omi- 
nous, as are also extensive suppurative processes. It is not good to 
see the eruption " sink in." The complications on the part of the 
kidneys, however severe the signs, though grave, are never neces- 
sarily fatal. From the gravest accidents recovery is still possible. 

Pneumonia, more often of such insidious onset as to have escaped 
detection at first, pleurisy with its wonted suppurative course, and 
peritonitis, intensely aggravate the prognosis. Peri- and endocardi- 
tis are almost necessarily fatal. An undue protraction of the disease 
by reason of reabsorption of products to constitute a relapse, or by 
reason of complications, makes the prognosis grave in correspondence 
with the intensity of the signs, duration of the disease, or character 
of the complication. Some of these cases succumb finally to atelec- 
tasis, heart failure, decubitus, marasmus. 

Prophylaxis. — Isolation is the only prophylaxis ; and inasmuch 
as the area of infection is so closely circumscribed, isolation is much 
more effective in scarlatina than in measles or small-pox. But as the 
disease may undoubtedly be carried by third persons, the attendants 
upon the sick should not come in contact with unaffected members 
of the family. The best protection is offered by removal from the 
house of all children liable to — that is, unprotected by previous attack 
of — the disease. Unaffected children remaining at home may not 
attend school or other assembly for several weeks after perfect re- 
covery of a member of the family. It is believed, whether it may be 
proven or not, that contagium emanates from the body so long as des- 
quamation continues, and the child should not be allowed to associate 



214 SCARLATINA. 

with its fellows until the last scale of skin has been removed. Des- 
quamation continues longest on the soles of the feet, and inspection 
of these parts gives the best answer as to the time when all desqua- 
mation shall have ceased. Such desquamation has been observed as 
late as forty days after the disappearance of the eruption, though it 
usually ceases entirely in less than half that time. 

Prophylaxis implies also the destruction or thorough disinfection 
of all articles which have come in contact, direct or indirect, with the 
patient. The room should be disinfected, ceilings whitened, walls 
rubbed down with bread, floors scrubbed with corrosive sublimate 
solutions, carpets or rugs beaten and suspended in the open air for a 
long time, bedding and clothing boiled if not buried or burned, or, if 
preserved, subjected to live steam. It is a sad comment upon our san- 
itation that public disinfecting stations are not yet established in all 
our cities and towns. Prophylaxis involves attention to detail. The 
disease has been conveyed by letters sent out from a sick-room, by 
cushions of chairs, curtains, piano covers, etc. Special attention 
must be paid to the discharges, to sponges, cloths, towels used in 
ablutions. The fact is that sponges, handkerchiefs, etc., are best 
substituted by rags, which may be immediately destroyed by fire. It 
must not be forgotten that the hair of the head retains and conveys 
contagium. Thorough ablution with soap and water or with the 
carbolized soaps will disinfect the hair. The hair of the boy patient 
should be cut short. It must be remembered even that the shoes 
require disinfection. They may be painted inside and out with car- 
bolic acid and glycerin, equal parts. Ventilation of the sick-room 
throughout the whole period of the disease is not only a necessity of 
treatment but also of disinfection. The frequent bathing of the body, 
with the subsequent application of some unctuous material — cocoa 
butter, lanoline, vaseline, etc. — not only gives great comfort to the pa- 
tient, but confines the poison to a narrower field. After the recovery 
of a patient, more especially after a death, outside windows should 
be thrown open and the room ventilated for a week. Here, too, at- 
tention must be paid to detail. Closet doors must be opened and the 
inside of closets with their contents disinfected and ventilated as be- 
fore. The fact is, the city government should take charge of all such 
apartments. They should be disinfected and ventilated under the 
inspection of health authorities. The inside doors to halls and other 
rooms should be closed by the seal of authority, and the same precau- 
tions taken as in the prevention of entrance or interference in cases 
of crime. Scarlet fever is for the most part spread by ignorance, 
by carelessness, by blunders which are worse than crimes. Refe- 
rence is made here to the premature return of children to schools or 
the constant attendance at school of unaffected members of a family, 



SCARLATINA. 215 

to contact which is effected in street cars, railroad trains, steamers, etc. 
Parents, nurses, even physicians, are all too careless in this regard. 

In the way of a drug there is no preventive of scarlet fever. The 
claim that a drug may protect against the disease, because when ad- 
ministered it produces a symptom which resembles that of the dis- 
ease, is, in the light of our present knowledge regarding the infec- 
tions, worse than mediaeval gibberish — worse because it may beget a 
sense of false security in exposure. This claim has been made for 
belladonna because it flushes the face. It has no more foundation in 
fact than protection by a blush, which has the same effect. Bella- 
donna, by making a child sick, rather predisposes to, than protects 
against, scarlatina. The hope that has been cherished regarding pro- 
tection by vaccination has proven equally vain. Attempts have been 
made to inoculate certain disease products of animals — horses, dogs, 
rabbits — with a view of producing a milder or more modified form of 
scarlatina. Claim has been set up in this direction, as by Strickler, 
who introduced the nasal mucus of horses supposed to have been af- 
fected with the disease into the bodies of twelve children, in all of 
whom it produced sores at the point of introduction, with circumja- 
cent inflammation of the skin and lymph glands. It was stated that 
these children thus inoculated failed to contract the disease after ex- 
posure to scarlatina. These experiments were made in imitation of 
the first experiments of Jenner with reference to small-pox, but the 
objections to accepting such conclusion are numerous and obvious. 
In the first place, it is not known that any of the lower animals really 
suffer scarlatina or any allied disease. Secondly, it has not been es- 
tablished by experiment that the disease which results from the in- 
troduction of scarlatinal matter of man into animals is really scarla- 
tina. Third, it could not, therefore, be known that matter taken 
from animals was the product of this disease. Fourth, susceptibility 
is so much less in scarlatina that failure to contract the disease after 
exposure has not the same weight -as in small-pox. 

Treatment is wholly symptomatic. The sick-room requires con- 
stant, thorough ventilation from the outside air. The temperature 
should be held at 65° to 70°, as registered by a thermometer, not at 
the door, window, or fire, but at the head of the bed. An open fire 
in winter is preferable to any other method of heating. The patient 
should wear a long muslin night dress, without other clothing. The 
bed covering must be as light as is consistent with comfort. 

Milk and meat soups make the best diet. Water, carbonated 
water, Selters, Apollinaris, lemonade, toast water, barley water, 
should be given freely to relieve thirst and to keep the kidneys 
ilushed. Drink should be proffered in fever once an hour during 
the day. 



216 ' SCARLATINA. 

The utmost cleanliness is to be maintained by frequent sponging 
and bathing of the surface. Daily tepid baths (full length) give the 
greatest comfort throughout the disease. Fever above 103° is best 
combated with cold sponges, cold packs, cold baths. Cold baths are 
most effective, but are seldom practicable as yet. It is not essential 
that the temperature be brought down to the normal degree. A re- 
duction of a few degrees suffices to give the patient comfort and re- 
lieves all danger attendant upon high temperatures. A warm or 
tepid bath will reduce the temperature one or two degrees, and pa- 
tients solicit such bathing when a cold bath may excite terror. While 
it is true that the temperature reaches the highest grades in scarla- 
tina and the patient suffers corresponding discomfort and danger, it 
is not true that the danger is caused by the fever. The danger, the 
discomfort, and the fever are produced by a common cause — namely, 
the poisoning of the blood — and there can be no question of radical 
therapy until after the discovery of some agent, some antitoxine, 
which will neutralize the chemical poison circulating in the blood. 
It is, indeed, a question if some fever be not salutary. We combat 
the fever in our day more especially with regard to the comfort of 
the patient. A difference of two degrees makes a great difference in 
the feelings of the patient. The reduction of high temperatures by 
cold bathing is attended, as a rule, with the diminution of discom- 
forts and dangers. The bath addresses the cause indirectly through 
its effects. The real virtue of the cold bath lies in the fortification of 
the heart. Frequent bathing is the best therapy in the treatment of 
scarlatina, as of any other infection. There may be reasons which 
render a bath impossible. In these cases resort must be had to fre- 
quent ablutions. It may become necessary to substitute a bath by 
drugs, especially in the presence of other indications. Resort may 
then be had to the antipyretics. Phenacetin is the least injurious. 
It may be given to a child in a dose of gr. ijss.-v., to an adult in 
double this dose, once or twice in the course of a day. It is of espe- 
cial value in headache or other nervous distress. It is best adminis- 
tered in capsule or in powder taken directly upon the tongue, stirred 
— that is, suspended — in milk, or, in case of high fever with dry 
tongue, floated upon the surface of a teaspoon of water. Only in 
case of failure with phenacetin should resort be had to antipyrin or 
antifebrin, either of which must be given in half the dose of phena- 
cetin. Burning and itching of the skin are best allayed by applica- 
tion, after tepid baths, of vaseline, cocoa butter, lanoline, goose grease,, 
bacon, or fresh lard. Quiet, peaceful, and more or less restorative 
sleep is wont to occur after a bath and inunction in this way. 

Nervous distress, jactitation, convulsions, insomnia, headache, are- 
best combated by bromide of sodium, gr. v.-x. to a child, gr. xxx.-xL 



SCARLATINA. 217 

to an adult, largely diluted ; or, if more obstinate, by sulphonal or 
trional, gr. v. to a child, gr. xv. to an adult, dissolved in a cup 
of hot milk or tea, or chloral, gr. v. to a child, gr. xv. to an adult. 
No other single remedy gives the comfort of chloral in small, 
two or three grain, repeated dose. Broken doses of Dover's pow- 
der, gr. i. to a child, gr. iij.-vi. to an adult, may substitute it in 
suitable case. Ice bags should be applied to the head for meningeal 
symptoms. The vomiting which occurs in the inception of the dis- 
ease is often sufficiently relieved by carbonated drinks, the best of 
which is the German Selters water with milk equal parts, or by 
lime water and milk one to three, by small doses of bismuth gr. 
v.-x., by the bicarbonate of soda in equal dose, by sips of water ex- 
cessively hot. The most powerful drug we possess is chloral. The 
most refractory vomiting, of whatever cause, will yield to the admin- 
istration of a few two- to five-grain doses of chloral diluted in a des- 
sert- to a tablespoonful of peppermint water. Should the remedy 
be rejected before it can be absorbed, it may be introduced into the 
bowel in double dose. It must be a remarkable case to resist chloral 
in one or other of these modes of use, or to justify resort at last to a. 
subcutaneous injection of morphia. 

Throat symptoms call for inhalations of steam, best from the 
steam vaporizer, simple or medicated with bicarbonate of soda, satu- 
rated solution, or boric acid 3 ij.- § iv., or carbolic acid 3 L- 3 iv., or 
thymol gr. v.- 3 i. alcohol, water § iii. ; or gargles of hot water, 
of carbolic acid gtt. xv.-xxx.- 3 iv., perchloride of iron 3 i.- 3 iv. ;. 
or direct applications of carbolic acid with glycerin equal parts,, 
bichloride solutions from 1 : 1000 to 1 : 100, or intraparenchymatous 
injections (tonsillar) of a few drops of the same solution by means of 
a hypodermatic syringe with a fine, long aspirator needle. Nothing 
keeps the throat so clean inside, whatever be its disinfecting proper- 
ties, as sprays of the peroxide of hydrogen as procured from the 
shops. Cloths wrung out of boiling water, applied about the throat 
and covered in by thick dry cloths, relieve the pains of extreme disten- 
tion. 

Affections of the ear are best treated by a douche of hot water 
and a Politzer inflation with air. Tension in the membrane of the 
tympanum may require puncture ; and suppuration in the mastoid 
cells, trephining. Earache is best relieved by instillation of hot 
water, or solutions of atropia gr. i.- § i. Otorrhcea is best treated by 
washing the external canal with a solution of boric acid after thor- 
ough cleansing with a cotton-wrapped sound, or direct application to 
accessible granulations of chromic acid, London paste, or the galvanic 
Cautery. Nephritis calls imperatively for hot baths, under which all 
the symptoms of this complication, including vomiting, are wont to 



'218 SMALL-POX. 

■speedily subside. The bath must be hot (100° to 110°), the patient 
rolled in blankets after it and be allowed to sweat for an hour. 

Rheumatism calls for the salicylates in saturating dose. Alcohol, 
•digitalis, nitroglycerin, may become necessities in the later course of 
all grave cases, and may be urged in over-dosage together with other 
analeptics — camphor, ether, musk — in the way of a " forlorn hope" 
in fulminant forms. 

SMALL-POX. 

Small-pox, or pocks (pock, a bag or sac) ; variola, diminutive of 
varus, a pimple (a term applied in ancient times to many eruptions, 
first limited to small-pox in the epidemics of France and Italy, 570 
a.d. [Hirsch]); German, Pocken, Blatter (blister). — A highly con- 
tagious, extremely dangerous disease, characterized by violent onset 
with severe chill, excruciating pain in the back and head, by an erup- 
tion of papules, subsequently converted into vesicles and pustules, 
whic h leave disfiguring pits or scars, and by a fever which remits at 
the period of papular efflorescence, to increase in the stage of suppura- 
tion. 

History. — Small-pox has existed from time immemorial in India, 
where temples were built and a goddess worshipped, and where, more 
to the purpose, the Brahmins practised inoculation in protection 
against it. Accounts of it in Africa date also from the most remote 
antiquity, and the great susceptibility of the negro race lends color to 
the view that the disease may have originated in these lands. It 
was imported into China probably about 200 a.d. Rhazes wrote his 
famous work concerning it in 900 A.D. 

Small-pox entered England in 1241 and Iceland in 1306, but did 
not reach Germany and Sweden until toward the close of the fif- 
teenth century. It was imported to America first in the West In- 
dies in 1507, exterminating whole races of natives ; next by Spanish 
troops into Mexico in 1520, where it carried off three and one-half 
millions of people. In the United States it reached Boston from 
Europe in 1649, and, though decimating the Indians in every direc- 
tion, made but slow progress and limited ravage among the white 
races, because of the introduction of vaccination in 1799, the period 
of commencing Western migration. Thus it did not reach Kansas 
until 1837, and California until 1850. Epidemics in South America, 
first in 1554, corresponded with the introduction of slaves from Africa. 
Certain islands of Polynesia remain as yet exempt. 

Small-pox has now only historic interest. It is on the road to 
extinction, and may occur in epidemic proportion only in uncivil- 
ized lands. As now seen it occurs in the modified form known as 



SMALL-POX. 219 

varioloid. Since the general introduction of vaccination, small-pox 
has lost all its terrors for those who recognize its absolute protection. 
In many parts of Europe small-pox patients are no longer isolated 
in pest houses, but are received into the general wards of hospitals, 
other inmates being protected by, if necessary, fresh vaccination. It 
is computed of the century preceding vaccination that fifty millions 
of people died in Europe of small-pox. Macaulay called it the most 
terrible of all the ministers of death. 

Etiology. — Susceptibility to small-pox is almost, though not 
quite, universal. The extent of immunity it is difficult to establish in 
our day because of the protection of vaccination. 

Age. — Though it spares no age, small-pox is essentially a disease 
of childhood, "interrupted and postponed by vaccination." Of the 
new-born, one-third die before their first, one-half before their fifth 
year of life (Werner). Old synonyms of the disease, Kinderpocken, 
Barnkoppen, attest this fact. 

Exemption of maturity and age is due, in some degree at least, to 
immunity secured by former attack. Accurate statistics disclose the 
fact that the disease occurs at all periods of life, even up to the ad- 
vanced age of sixty and seventy. 

Sucklings enjoy some immunity. Liability grows intense at the 
end of the first year and continues up to fort}^, when it becomes less 
marked. Pregnancy and puerperium rather invite than repel the 
disease. Small-pox may certainly attack the foetus in utero after 
the fourth month, and children have been born in every stage of the 
disease. 

The disease is severe with the colored race. This fact has been 
noticed not only in their own country, but in all lands to which they 
have been carried. The more frequent disfiguration of the colored 
race seen upon the streets is due partly to this cause, but chiefly to 
neglect of vaccination. 

One attack, however light, confers immunity for life, with occa- 
sional rare exceptions. Louis XV. of France survived an attack 
at the age of fourteen and died of the disease at sixty-four. One 
successful vaccination likewise protects, but with more frequent ex- 
ceptions. 

Epidemics occur more frequently in the colder seasons, partly 
oecause of the closer contact of people at this time, chiefly because of 
the concentration of the contagium in less ventilated rooms. 

The contagious principle of small-pox certainly exists in the skin, 
"whence it is disseminated about the body of the patient. Inocula- 
tion was formerly practised wholly by the matter of the disease in 
the skin. It was the custom in China in the most ancient times to 
introduce the crusts of small-pox matter into the nose in the process 



220 SMALL-POX. 

of inoculation, and in India to rub the matter on an abraded skin. 
The fact of infection of the foetus, which is undeniable, proves that 
the poison exists in the blood. There is, however, no proof of the 
existence of the poison in any of the various secretions or excretions 
of the body. Doubt was thrown upon even the infectiousness of the 
blood, until Zulzer succeeded in communicating the disease to a. 
monkey with the blood of a variolous patient. 

The contagious principle has singular tenacity of life. It sticks 
especially to bedding and clothing, which, if kept secluded at a 
warm temperature, may remain infectious for months, and even 
years. It is certain that the pox has been contracted by an in- 
dividual who has approached a patient no nearer than three feet, 
and it is well established that the disease may be conveyed by third 
persons and by things. The contagion is given off from the body at 
all periods of the disease. Proof of the transmissibility of the dis- 
ease during incubation was offered by Schaper in the case of an in- 
dividual who had some particles of skin engrafted upon an ulcer. 
The particles were taken from an amputated arm of a person during 
the period of incubation of small-pox. The patient was attacked by 
variola on the sixth day after the operation. 

Bacteriology. — The contagious principle or cause of the disease 
has not yet been isolated, the micro-organisms discovered being 
those only of pus. V. Loff claims to have developed in sterilized 
tubes, from fresh matter, amoebae or proteids. Pfeiffer claims to 
have discovered as constantly present in the exanthem of variola a 
parasite of the species protozoa, which runs its whole course of de- 
velopment in the body of man or other mammal. According to 
Koch and Schulze our present methods will not suffice to unveil the 
virus of variola. 

Symptoms. — The period of incubation varies from ten to four- 
teen days. Invasion is ushered in by a chill, which is, as a rule, 
violent, with rise of temperature to 103° to 104° on the first day. 
Prostration is pronounced from the start. Anorexia, vomiting, 
jactitation, insomnia, and severe headache set in at once. Above 
all other signs pain in the loins assumes prominence. It accom- 
panies the fever from the start, and subsides only with its fall with 
the appearance of the eruption on the third day. 

Inasmuch as the eruption proper does not appear until the third 
day, especial value attaches to two rashes of earlier occurrence in 
certain cases or in certain epidemics. One is petechial, the other 
erythematous. Petechise appear on the second day in the form of a. 
fine macular or spotted eruption in the space known as " Simon's 
triangle," whose base is at the umbilicus, apex at the knees. It may 
occur elsewhere, especially in the space under the axillae. The ery- 



SMALL-rOX. 



221 



ihematous eruption has its favorite seat on the sides and inner sur- 
faces of the legs from the ankles up, sometimes, in women, about the 
nipples. This eruption indicates a mild case of the disease, whereas 
petechise have no such prognostic value. 

Petechise should never be mistaken for the true hsemorrhagic 
eruption, which may stamp the disease from the start or occur at any 
later period. Both these eruptions disappear, as a rule, in twelve to 
twenty-four hours. They may last longer, and they may, especially 
the p3techia3, leave behind them slight brownish colorations. 

The true eruption in its very first appearance is purely macular. 
In the course of the very first day, however, the macule is thickened 




Fig. 133.— Pock of small-pox; a, outer layer of epidermis; &, middle layer; c, rete Malpighi ; 
■d, reticulated cavity of pock containing pus corpuscles, with the epithelial framework; e, purulent 
infiltration of epidermis (Curschmann) . 

to become a papule. It shows itself first on the face and scalp, 
where it is unfortunately always worst, over the forehead and tem- 
ples, then upon the sides of the nose, about the lips, over the chin, 
and spreads thence downward in quite regular progression over the 
body. Surfaces rendered hypera3mie, as by poultices or mustard 
plasters, show more profuse eruption. The hands and fingers fur- 
nish the next most favored surfaces. The eruption disappears upon 
pressure, yielding to palpation a sense of hardness, as of shot under 
the skin. It is always discrete at first. By the sixth day the papules 
contain fluid. They become vesicles and protrude like half-peas. 
These vesicles are peculiar in showing later a central depression or 



222 



SMALL-POX. 



umbilicus, which is most marked just before the vesicles change 
into pustules. The depression is explained in this way : The vesicle 
is not a single sac. It is reticulated — i.e., many-celled — in structure, 
so that puncture evacuates only part of its contents, and the bands 
which form the reticula hold down the surface more firmly at one 
point, perhaps the site of a hair follicle, sweat gland, or firmer strip 
of connective tissue. Effusion takes place between the upper and 
lower layers of the epidermis with the dissolution of these bands. 
In three days more the umbilicus disappears, the vesicle becomes a. 
pustule which is full, round, and large ; the half becomes a whole 
pea. With the coalescence of pustules walls are broken down, dis- 
solved, and eroded. The eruption becomes confluent. 

The eruption of small-pox 
appears also on the inside skin, 
the mucous membrane of the 
mouth, pharynx, and some- 
times deeper structures. It may 
be nearly always discovered in 
the fauces, over the palate and 
tonsils, and sometimes on the 
inner surfaces of the lips and 
cheeks. Occasionally it invades 
the larynx. Ulcers may form 
in the larynx, with affection of 
the cartilage, perichondritis, and 
oedema of the glottis. In a bad 
case the tongue, which seldom 
shows any sign of eruption, is 
Tem ^ ratu . reehartinvariola ' sbowing swollen to such an extent as to 

protrude from the mouth, and 
salivation may be profuse. The affection may also extend from the 
throat to the nose, which it may block from behind, and subsequently 
involve the Eustachian tubes and middle ear. Mucosae of other 
parts of the body are rarely attacked. 

The course of the temperature in variola is characteristic. The 
fever reaches its height, as stated, with the period of eruption. So 
soon as the eruption has covered the body the temperature begins 
to subside, and falls often nearly to the normal grade within thirty- 
six hours. With the subsidence of the temperature the pain in the 
back, the nausea and vomiting, disappear, and the patient seems on 
the road to recovery. So soon, however, as the vesicles become con- 
verted into pustules, about the sixth to the ninth day of the disease, 
fever is renewed, sometimes with shivering fits, always with a rise of 
temperature to 102° or 103°, but rarely to the elevations reached dur- 



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secondary fever (Moore) 



SMALL-POX. 223" 

ing the stage of invasion. This is the secondary fever, the fever of 
suppuration, caused entirely by the micro-organisms of pus. Strictly 
speaking, it does not belong to the small-pox process. It is a secon- 
dary effect, but is none the less characteristic of the course of the dis- 
ease. With the stage of desiccation the fever again gradually sub- 
sides, to terminate by lysis in the course of the subsequent week. In 
the height of confluent small-pox the stage of vesiculation is repre- 
sented by an accumulation of a more or less milky fluid over flat sur- 
faces, often in irregular or zigzag shapes. The swelling is greater, as. 
is also the corresponding deformity at the period of suppuration. 
The eyes and the ears are blocked, the face is enormously bloated, 
the scalp is lifted from the head, and the face has the appearance as 
if covered with a mask or heavily coated with coarse sand. With 
the rupture of this parchment-like coat masses of decomposing fluid 
ooze out, to stream down over the face and make of the patient an 
object so loathsome to sight and smell as to be repulsive. 

Chief among the varieties of small-pox are the abortive and 
haemorrhagic forms. The abortive is that variety in which the- 
course of the disease is altered from the start. The period of incuba- 
tion is sometimes shortened, the invasion may be brief, the eruption 
changed in various ways, or the duration cut short. This form is 
best described under the rather unfortunate denomination, vario- 
loid. 

Haemorrhage may occur in the course of small-pox in no less than 
four distinct varieties: 1. Blood is not infrequently effused in the 
vesicles or pustules of patients who do not remain recumbent, who- 
leave the bed and get up too soon in the period of convalescence. In 
these cases the haemorrhage is confined almost exclusively to the- 
lower extremities, and shows itself as petechiae or purpura, not un- 
like the common form of this affection. Such haemorrhage is purely 
local, due to escape of blood through paretic vessels. It speedily 
subsides by absorption with rest in* bed; it has no prognostic gravity. 

2. Reference has already been made to that petechial eruption 
which occurs as an initial rash on the lower surfaces of the abdomen 
and inner aspect of the thighs. This eruption has also a haemor- 
rhagic foundation. It is of diagnostic value, but has no prognostic 
significance. 

Aside from these eruptions, 3, blood may be poured out into the 
true eruptions of small-pox at any part of the course of the disease. 
This accident occurs most frequently in cases debilitated by previous- 
disease or bad surroundings, but sometimes, fortunately exception- 
ally, under totally unaccountable circumstances. The blood is 
effused at times into the papules, more frequently into vesicles at the 
period of full maturation — i.e., at the height of the disease. The^ 



224 SMALLPOX. 

clear serum becomes turbid, sero-sanguinolent, and finally the vesi- 
cle is filled with blood. Sheets of blood, diffuse and black, fill the in- 
terior of confluent vesicles and pustules, and blood appears under the 
;skin as livid patches, vibices, and ecchymoses, in various parts of the 
body, to constitute what is called hcemorrhagic small-pox, black 
small-pox, " variola nigra." With this effusion of blood there is cor- 
responding collapse. Free haemorrhages may occur also from the 
various mucous surfaces, under which the patient rapidly succumbs. 
Should the patient survive the prostration caused by the haemorrhage 
itself, he may have to face other and worse dangers. Diphtheritic 
deposits form in the pharynx, a scorbutic condition of the gums, or 
nephritis ensues and the patient may perish from uraemia. Recov- 
ery from this condition is rare; convalescence is slow and tedious. 

Last among the haemorrhagic eruptions remains to be described, 4, 
that particular variety in which the haemorrhage assumes prominence 
over all other signs. This variety presents such distinctive features 
as to have led competent observers to consider it a special malady. 
The fact that the disease, in any of its forms, may be communicated 
from this form, and that the body remains infectious also after death, 
establishes its true nature. That this haemorrhagic form may be 
distinguished from those just described, especially from the variola 
haemorrhagica pustulosa, it has been given the separate name of 
"purpura variolosa" — a term which fixes in the foreground the 
haemorrhagic character which literally dominates the disease. In this 
variety of small-pox the initial rash and the true eruption are alike 
wanting. Although this is the fulminant form of small-pox, it does 
not necessarily commence with violent signs. It attacks, by preference, 
the young, healthy, and strong, but does not spare the weak and de- 
bilitated. Drinkers and pregnant and parturient women are among 
its especial victims. 

The disease begins in the ordinary way, with chill, vomiting, and 
rapid prostration. The stage of invasion (if it differ in any way 
from ordinary cases of small-pox) is distinguished by the severity 
of pain in the back. In the experience of the author, patients have 
complained of excruciating pains in the back when there was no 
other symptom, not even fever. Another distinctive feature is the 
rapidity of appearance of haemorrhage. Should the disease occur 
during menstruation, metrorrhagia ensues and the nature of the dis- 
ease may be thus overlooked, as the pain and the haemorrhage may 
be both connected with menstruation. Haemorrhage now shows itself 
under the skin, first upon the trunk, later upon the extremities, but 
never upon the face. The surface assumes a blood-red hue, like that 
of scarlet fever, and in this redness points and patches of blood ap- 
pear. The eruption is usually petechial upon the extremities, and 



SMALL-POX. 225 

confluent as irregular ecchymotic patches on the chest and trunk. 
The face is swollen, the eyes suffused and sunken and surrounded 
with black rings. The tongue is thick and heavily coated. The 
breath is exceedingly fetid. There may be elevation of temperature ; 
sometimes there is no fever, and often the temperature is subnormal. 
The tendency is steadily downward, and death occurs by the end of 
the first week. Fortunately this form occurs in but five per cent of 
cases. 

A peculiar variety or disposition of eruption is that described by 
Marson as " corymbose." In these cases the eruption shows itself in 
patches or clusters the size of the hand, as thickly set as possible, 
while the surrounding skin remains often entirely free. The patches 
are often symmetrically distributed upon the extremities. The vari- 
ety is very rare, but, contrary to what might be expected, is very 
dangerous. Other singularities are verrucose, pemphigose, or mili- 
ary eruptions. They are, however, more commonly encountered in 
varioloid. 

Varioloid is a misnomer, for the affection is not like variola, it is 
variola itself. Varioloid does not stand in the same relation to vari- 
ola as typhoid to typhus fever; varioloid is variola in modified form. 
Varioloid is the lightest form of small-pox. The disease occurs in 
this form on account of natural insusceptibility, or on account of pre- 
vious attack, formerly on account of inoculation. The great major- 
ity of cases seen in our day are due to incomplete protection by 
vaccination. The immunity secured by vaccination has run out, and 
the severity of the attack will, to a certain extent, depend upon the 
remaining degree of protection. A case of unmodified variola in our 
day is a rarity; that modified or mitigated variola known as vario- 
loid is still frequently seen. A knowledge of the nature of varioloid 
and its differences from other simulating affections is necessary, 
that the disease be recognized at once, in protection of others. From 
what has been stated, it is needless to add that varioloid, mild as it 
may be in itself, may transmit true variola, in any, even its most 
fulminant forms. Most of the cases encountered in our day are so 
mild that the question of diagnosis concerns differentiation of vario- 
loid from varicella as much as the recognition of variola itself. Va- 
rioloid distinguishes itself by abnormities in every phase of the dis- 
ease. As most of the cases are due to incomplete protection by 
vaccination, the various irregularities are mentioned by Morrow 
when he says that "vaccination denaturalizes small-pox, deranges 
the original order of the disease, and effaces its most distinctive fea- 
tures." 

It is generally assumed that the modification of symptoms is ap- 
parent in the initial stage of the disease ; this view, however, is by 
15 



226 SMALL-POX. 

no means correct. The disease begins with its usual train of symp- 
toms, and, as a rule, with its original violence. The difference con- 
cerns duration rather than degree. The initial stage is often cut 
short a day or two, so that the eruption may appear by the end of 
the first or second day. The various initial eruptions occur also in 
varioloid ; the petechial as an exception, the erythematous as a rule. 
It is a common observation that a pronounced erythematous erup- 
tion or scarlatiniform rash betokens varioloid rather than variola. 
Curschmann declares that we may predict, in spite of the severe 
depression of the general system, that the form of the disease, if 
erythematous, will be mild, while petechiae will nearly always be 
followed by variola vera, which is not infrequently confluent. For 
what comfort it may bring, the author may state that the cases of 
petechial eruptions in Simon's triangle which have occurred in his 
experience have preceded, without exception, a mild, abortive attack 
of the disease. 

With regard to the real eruption, varioloid presents the greatest 
variations. It may begin on the scalp, forehead, and temples, as in 
an ordinary case, and progress in irregular course. It may, on the 
other hand, show itself first on the neck and chest, or elsewhere over 
the trunk, to appear later on the extremities or face. As a rule it is 
much less abundant, so that it is nearly always discrete. There are, 
however, exceptions to this rule, and marked cases may show iso- 
lated patches of confluence on the face and hands. On its first 
appearance the eruption differs in no way from that of the more 
pronounced form of the disease. It comes out in spots, which are 
elevated into papules in the course of the first day. The papules 
slowly show fluid at their acuminated apices, and become thus 
entirely converted into vesicles as before. Here, now, the change is 
usually observed ; the eruption usually stops at this stage, and the 
vesicles, which may have become umbilicated, begin to dry up and 
disappear. They may fill out, as in the course of severer forms ; 
their contents may become turbid and opaque, and the vesicle may 
be transformed into 'a pustule ; but it is plain to see that the force of 
the disease is spent. Certain pustules may rupture, but the process 
is limited and the secondary fever of suppuration is reduced or is 
entirely absent. In consequence of the fact that pustulation does 
occur in places, with erosion and destruction of tissue, pits may be 
left, but they are few and far between as compared with the lesions 
of ordinary small-pox. 

The disturbance of the general progress of the disease is marked 
also by irregularity. It is more common to find pustules and vesi- 
cles, or vesicles and papules, in closer proximity in varioloid than 
in variola. Moreover, the eruption does not last so long. Desicca- 



SMALL-POX. 227 

tion begins on the fifth or seventh day, and most of the papules dry 
up into crusts without rupture. These crusts, as a rule, leave only 
pigmented traces without scars. There is often also disproportion 
between the severity of the fever and the eruption. There may be 
high fever in the presence of but ten or twenty vesicles or pustules 
over the body, or, per contra, the eruption may be almost or. in 
places, even confluent with but little elevation of temperature. It is 
plain to see that vaccination has at every point put a muzzle upon 
the disease. 

The various transformations of vesicles and papules which may 
occur during the process of modification or abortion may convert 
vesicles or pustules into warty masses, or bulla? ; or ruptured vesicles 
may fill with air, to constitute varieties known as variola verru- 
cosa, pemphigosa, miliaris, ventosa, or cellulosa. etc. So of the 
various affections of the mucous membrane. While they may be 
present, or in individual cases more or less pronounced in initial 
stages, they rarely assume prominence or give rise to serious compli- 
cations. 

Complications which occur in the course of small-pox do not 
differ much from those of equally grave acute infections. Sufficient 
mention has already been made of the lighter affections of the pha- 
rynx and larynx. It remains to be said that gangrenous processes, 
oedema of the glottis, perichondritis occur in exceptional cases. 
Stenosis from either of these causes may necessitate intubation or 
tracheotomy. 

Bronchitis belongs to variola, as to most of the exanthemata. It is 
very liable to extend in childhood, to infect the finer bronchial tubes 
and result in broncho-pneumonia. Pleurisy is by no means so com- 
mon, but is by no means rare. Pericarditis, endocarditis, endome- 
tritis, meningitis, are not uncommon complications in grave cases. 
Affections of the joints, arthritis, pyaemia, septicaemia, are much 
more frequent. 

Small-pox occasionally affects the eye : conjunctivitis, keratitis, 
affections of the fids, are the most common lesions. Disease of the 
choroid and retina occurs in exceptional cases. Panophthalmitis with 
destruction of the globe was not uncommon in ancient times. Eye 
complications in our day are neither frequent nor severe. In all his 
remarkable experience Hebra saw eye complications in only one per 
cent of five thousand cases of small-pox. 

By extension of the inflammation of the fauces and pharynx the 
middle ear may be attacked, to result in otitis or otorrhcea with sub- 
sequent anchylosis of bones and deafness. Phlegmonous inflam- 
mations, gangrene of the skin, furunculosis, occur frequently in con- 
fluent cases, and local and diffused inflammation of the brain and 



228 SMALL-POX. 

cord, paralysis, bed sores may nearly complete the possible compli- 
cations. 

The diagnosis of the disease rests upon the following points : the 
possible existence of other cases, the history of sufficiently recent 
protection by vaccination. The mere existence of a scar is no evi- 
dence of protection. The worst case of purpura variolosa encountered 
in the experience of the author had three well-marked cicatrices upon 
the arm as evidence of previous vaccination. Then it is observed 
that the illness sets in suddenly and is usually severe from the start. 
Strong men stagger as if drunk. The temperature rises rapidly. 
Pain in the back is peculiar in its intensity ; initial eruptions may 
be characteristic. The true eruption appears upon the third day 
after the initial chill. It is maculated, not punctate like, that of scar- 
latina, but darker than the scarlet of scarlatina and lighter than the 
dusky hue of measles. It is seen first upon the scalp and upper 
part of the face, spreading downward regularly and rapidly ; it does 
not spare the nose or region of the mouth. It yields a peculiar feel- 
ing of hardness, as of shot under the skin. Elevation into papules 
occurs during the first day. The diagnosis becomes nearly certain 
when the papules by the third day change into vesicles, some of 
which subsequently become umbilicatecl. 

Small-pox is one of the most grave of the acute infections which 
survive from the pre-sanatory period of civilization. We see it for 
the most part as a mere relic or rudiment of its former self. There is 
lacking with us that element of multitudinous infection which gives 
volume and virulence to a disease. Nevertheless even in its modi- 
fied form it preserves its character as a grave infection, and it may 
hence be confounded with any of the infections of equal gravity, es- 
pecially with any attended with an eruption. 

Disregarding the eruption for the present, because not manifest at 
the start, mistakes have thus arisen in connection with meningitis, 
pneumonia, and typhus fever. Meningitis, especially the cerebro- 
spinal form, pneumonia and typhoid fever, begin, like small-pox, in 
the midst of health, with violent chill, rise of temperature, and rapid 
prostration. Gastric symptoms, vomiting or nervous shock, espe- 
cially, in children, convulsions, may announce the onset of any of these 
infections. In the absence of an epidemic or the history of exposure, 
in the absence also of adequate protection by vaccination, the diag- 
nosis must sometimes be held in abeyance for twenty -four or forty- 
eight hours until distinctive signs of one or the other of these diseases 
are manifest. Meningitis distinguishes itself by hypersesthesia, opis- 
thotonos, and herpes, as well as by its irregular temperature curve. 
Pneumonia is early characterized by pain in the side, cough with 
glutinous and rusty sputum, and increase of respiration out of pro- 



SMALL-POX. 229 

portion to the pulse. But the diseases which are most frequently 
confounded with small-pox are those which are attended with an 
eruption, and chief among these is typhus fever. But typhus fever 
has a history of importation which may be traced, or prevalence 
which may be known. It begins often like small-pox, suddenly, with 
a severe chill, in the midst of health, and shows an eruption on the 
third day. The eruption of typhus, however, appears first upon the 
body, chest, and abdomen in the form of maculae, which soon become 
petechial. The eruption of small-pox appears first upon the scalp and 
forehead, and progresses over the face before it appears upon the 
body. It shows itself in the form of macula?, which soon become 
papular, vesicular, etc. The petechias which may occur in small-pox 
occur on the legs or thighs, or in the course of a haemorrhagic form. 
Vesicles, especially umbilicated vesicles, are never seen in typhus 
fever. There is also characteristic difference in temperature, which 
subsides with the appearance of the eruption in small-pox, but per- 
sists unaffected for several days or as long as a week in typhus 
fever. 

Confusion with typhoid fever is less pardonable. Typhoid fever 
begins insidiously, requiring the time of a week to reach the eleva- 
tion of temperature of small-pox in a day or two. The cloud about 
the brain, which belongs both to typhoid and typhus fever from the 
start, is not present in small-pox until the last stages of the disease. 
Typhoid fever shows abdominal symptoms, roseola on the seventh 
to tenth days, meteorism, gurgling, diarrhoea, etc., absent in small- 
pox. 

A light case of small-pox may be regarded as measles, and a 
bad case of measles as small-pox. Consequently the separation of 
small-pox from measles is the most frequent problem submitted to 
the practitioner. The future of the case, the safety of the commu- 
nity, the reputation of the physician, depend upon the proper solu- 
tion of this problem. Here, too, Kelp may be had by a knowledge of 
the history of the case as to the existence or absence of an attack of 
measles or small-pox, the period of the last successful vaccination, 
the prevalence of either disease in the community. As for measles, 
it is always present in cities. Thanks to the popular fear of small- 
pox, knowledge of its existence is early promulgated by the health 
authorities. Nevertheless sporadic cases steal in at times unan- 
nounced. In the experience of the author with the management of 
a large dispensary practice, small-pox was twice introduced into Cin- 
cinnati by the peripatetic philosophers commonly called "tramps." 
These cases formed centres of infection. Knowledge of the period 
of exposure — i e., the period of incubation — is of little value. The 
stage of invasion is much milder in measles than in even modified 



230 SMALL-POX. 

forms of small-pox, for, as has been stated, varioloid may be an- 
nounced with symptoms as severe as those which distinguish the 
onset of variola vera. The chill is less severe, the fever is less high, 
the prostration is less profound in measles as a rule. There are, of 
course, exceptions on both sides. The eruption appears on the third 
day of small-pox, on the fourth day of measles. The maculae of 
measles are bigger than those of small-pox. They appear also upon 
the back almost at the same time as upon the face, whereas the erup- 
tion of small-pox much more uniformly appears upon the face and 
reaches the back only later in its advance over the body. The ma- 
culae of measles are softer than those of small-pox. Khazes said, 
nearly a thousand years ago, the difference between the two he 
found to be "that measles are red and appear only on the surface of 
the skin without rising above it, while the small-pox consists of round 
eminences. When these eminences appear, fix your attention on 
them, and, if you are in doubt as to the disease, do not express any 
opinion about it for a day or two ; but when there are no eminences 
you must not give as your opinion that the disease is small-pox." 
And Collie, a recent writer, observes : "A case of small-pox severe 
enough to simulate measles imparts to the hand, in passing it over 
the surface, a hardness and furrowed roughness, as that produced in 
passing the hand over a piece of corduroy ; whereas in raised, con- 
fluent measles it is that of passing the hand over a piece of velvet. " 
The catarrhal symptoms, more especially the coryza, which may ex- 
ist in both affections, are wont to be more prominent in measles at 
the start, but persist longer in small-pox. The course of the tem- 
perature is characteristic in the two diseases. The appearance of 
papules or vesicles soon dissipates all idea of measles. 

The severity of the sore throat, the backache, and the scarlet 
color of the rash, which appears as minute points as early as the 
second day after the initial chill, distinguish scarlet fever. The 
grave hemorrhagic form, "purpura variolosa," is recognized by the 
extreme severity of pain in the back, as well as by the petechial char- 
acter of the eruption, free haemorrhages, etc. 

Papular eczema is irregular in its distribution, unattended with 
fever or involvement of the mucous membranes. The same excep- 
tions apply to erythema, acne, and herpes. Only the most super- 
ficial observer could consider these eruptions variolous. 

' Syphilis may show pustules to closely resemble discrete variola, 
including even the process of umbilication; but the absence of the in- 
itial signs — chill, fever, pain in the back, etc. — the history of syphilis, 
or associated evidence elsewhere, render the diagnosis easy as a rule. 

The separation of variola and varicella will be discussed under 
"Varicella." 



SMALL-POX. 231 

All cases concerning which there is any do-nbt should at least be 
isolated for a time until sufficient protection can be offered to oth- 
ers by vaccination. Marson says of his experience in the London 
small-pox hospital : " Upward of twenty diseases have been mis- 
taken within the last few years, in the early stage of the disease, for 
small-pox, and the patients have been sent, as having small-pox, to 
the small- pox hospital." 

The prognosis is largely determined by the last successful vacci- 
nation. The next most important factor is the determination of the 
form of the disease. The third is the age of the patient. Small-pox 
in infancy has a mortality which is put at ninety per cent. Almost 
equally grave are the cases which occur in pregnancy and the puer- 
perium. The greater danger which is thus imparted to the female 
sex is counterbalanced in the male sex by the mortality of the disease 
among drinkers. The percentage runs high, again, in advanced age ; 
nearly seventy-five per cent of old people, unprotected by vaccination 
or previous attack, succumb to the disease. 

Severe symptoms on the part of the nervous system are of evil 
omen, but to a less degree in children than adults. Trousseau laid 
great stress upon tumefaction of the extremities, what he calls "red 
oedema," which should set in at the end of the ninth day with acute 
pain ; with Sydenham, Morton, Van Swieten, Borsieri, he attaches 
great importance to it in a prognostic way. He says: " Swelling of 
the hands and feet is such a necessary phenomenon in confluent 
small-pox that patients almost invariably succumb where it is ab- 
sent, unless there be a great critical discharge by the kidneys or 
bowels." Profuse suppuration in the skin is a sign of danger. 
Hemorrhagic small-pox is very serious; less than one-half the cases 
recover. But the prognosis is not unfavorable because of initial 
petechia?, which may show later upon the legs of patients who try to 
get about too soon. Purpura variolosa is always fatal. The mor- 
tality of the unvaccinated ranges, even in our day, at twenty to forty 
per cent. 

Prophylaxis. — Vaccination, if it could be enforced, would render 
superfluous all other prophylaxis, including isolation. Inoculation, 
which it substitutes, has only historic interest. Vaccination and re_ 
vaccination, if it could be made compulsory, would eventually eradi- 
cate the disease; thus but a single fatal case of small-pox has occurred 
in the German army during the past twenty years. Unfortunately, 
however, vaccination cannot be made compulsory in our country, 
' ' where the cry of infringement of personal liberty is the shibboleth 
of the demagogue" (Foster), so that patients must still be isolated 
and sick-rooms disinfected. A temperature of 400° P. is fatal to 
small-pox. The organisms of the disease are destroyed by sulphur 



232 SMALL-POX. 

in sufficient concentration. That this process may be properly 
brought about, it must be done by health authorities. All combus- 
tible material should be consumed, if it may not be subjected to the 
antimycotic action of live steam; walls should be rubbed down with 
bread; floors scrubbed with a solution of corrosive sublimate 1 : 1000; 
doors and windows should be closed, and sulphur, four pounds to 
every 1000 cubic feet of air, should be burnt to bring about perfect 
fumigation; at the end of two days the chamber may be thrown 
open and thoroughly ventilated for two weeks. Bedding, clothing, 
curtains, etc., after subjection to superheated steam, should be sus- 
pended in the open air, day and night, for a week. 

The dead body should be subjected to immediate interment, as 
infection is disseminated from its surface up to the period of decom- 
position. In the interval between death and burial the body should 
be enveloped in a sheet saturated in the solution of corrosive subli- 
mate 1 : 1000. Transportation should be permitted only when a 
body is put in an air-tight metal case. In the experience of the 
author an epidemic was once developed at a distance in a country 
town by neglect of this precaution. 

Treatment.— li seen early the patient should be vaccinated at 
once. Vaccination modifies variola in the early stage of the disease. 
After the fourth day vaccination is useless. Marson puts it posi- 
tively: " Suppose an un vaccinated person to be exposed to small-pox 
on Monday; if he be vaccinated as late as Wednesday the vaccination 
will be in time to prevent small-pox being developed; if it be put off 
until Thursday small-pox will appear, but will be modified ; if the 
vaccination be deferred until Friday it will be useless — it will not 
have had time to reach the stage of areola, the index of safety before 
the illness, and indications of small-pox begin/' Curschmann does 
not subscribe to these points. He declares that he has seen, in cases 
in which vaccination was practised, that infection with vaccinia and 
small-pox pustules developed side by side. He doubts whether vac- 
cination can render the disease even milder in its course. Neverthe- 
less so long as there is doubt the patient should have the possible 
benefit of early vaccination. 

Treatment, in the absence of a specific, is wholly symptomatic: 
Rest in bed in a thoroughly ventilated room at a temperature of 65° 
F., as determined by a thermometer at the head of the bed; light but 
sufficient covering; cool drinks — water, lemonade, Selters water, in 
sufficient quantities; fever diet — milk, soups, gruels. Thus much we 
owe to Sydenham. What it must have effected may be learned by 
what it substituted. The contrast is shown in a chapter from the 
practice of Diemerbroeck : "Keep the patient/' says Diemerbroeck, 
"in a chamber close shut; if it be winter, let the air be corrected by 



VACCINATION. 233 

large fires; take care that no cold air gets to the patient's bed ; cover 
him over with blankets. Never shift the patient's linen till after 
the fourteenth day, for fear of striking in the pock to the irrecover- 
able ruin of the patient. Far better it is to let the patient bear with 
the stench than thus be the cause of his own death." Trousseau is 
right when he says: " If the second epoch in small-pox was introduced 
with inoculation, and the third with vaccination, the first was intro- 
duced with the treatment of Sydenham." 

Fever above 103° can best be combated by frequent baths, or by phe- 
nacetin or salipyrin gr. x., or antipyrin gr. v., or in half of these 
doses in childhood. For throat complications, steam from an atomizer, 
simple or medicated with boric acid gr. xv.- § iv., thymol gr. xv., 
alcohol and water aa 3 ij., or carbolic acid or creosote 3 ss.- f i. alco- 
hol to 1 iij. water, or, with less efficacy, gargles of the same strength. 
Inhalations may substitute all local applications in very young or 
refractory children. Chloral, gr. ii.-x., becomes a necessity in peri- 
ods of unrest, nervousness, insomnia. It has no equal in the relief 
of nausea and vomiting. For jactitation or extreme nervous distress 
it may have to be substituted by Dover's powder gr. ii.-v. Frequent 
ablutions of tepid water, ointments, diachylon ointment, plasters, mer- 
curial plaster, or opening pustules after the manner of the Arabs 
and touching them with nitrate of silver, or, better, with equal parts 
of carbolic acid and glycerin, or touching the tops of beginning pus- 
tules — i. e. , mature vesicles — with a camel's-hair brush dipped in car- 
bolic acid, best prevent or limit pitting. Xylol internally is said 
by Ziilzer to have the power of coagulating the contents of pustules, 
but the claim was not at all substantiated by subsequent trial. 

Where tissue is destroyed cicatrization must result, and, in con- 
sequence of it, pits and scars. Means to prevent deformity, to be 
effectual, must therefore be brought into use before the stage of 
suppuration is complete. Nothing can prevent pitting in an estab- 
lished confluent small-pox. The best clinicians are content with fre- 
quently renewed water dressings, made antiseptic as much as may be 
with sublimate solutions 1 : 5,000-10,000 or with one-per-cent solu- 
tions of creolin. The whole question, with all the other horrible evils 
of small-pox, sinks into insignificance and slinks away, like the devil 
at sight of the cross, when brought face to face with vaccination. 

VACCINATION. 

Vaccination (vacca, a cow); vaccinia; cow-pox. — The inoculation 
of man with cow-pox in prevention of small-pox. The promulgation 
of vaccination by Edward Jenner in 1798 constitutes one of the great 
epochs in the history of mankind, in that from this period the tropi- 
cal plague variola, which overran and literally decimated Europe and 



234 VACCINATION. 

the rest of the world, was reduced to » the trivial malady varioloid T 
which is, uncomplicated, never fatal. 

History. — Jenner was a medical apprentice at Sodbury when he 
became acquainted with the popular belief in the protective influence 
of cow-pox, a subject which he was unable to dismiss from his mind. 
He visited Gloucestershire, and made observations and prosecuted 
the investigations for himself. He found that there existed a wide- 
spread belief amongst the dairymen that certain individuals who 
had contracted sores upon their hands from contact with sores on the 
bags of cows were never attacked with small-pox. Much contradic- 
tory testimony presented itself at first, and many disheartening ex- 
ceptions were found. 

May 14th, 1796, is the memorable day when Edward Jenner 
transferred cow-pox from vesicles on the hands of Sarah Nelmes, a 
dairymaid, by means of two superficial incisions, into the arms of 
James Phipps, a healthy boy eight years of age. The cow-pox ran 
its ordinary course, and a subsequent inoculation with small-pox on 
the 1st of the following July failed to produce the disease. This, 
was the first attempt of a simple practice which has within less than 
a century, and without radical correction or real improvement, af- 
forded to all mankind protection from the ravages of small-pox. A 
number of children subsequently vaccinated in succession, " one 
from the other," were, after several months, exposed to the infection 
of small-pox, "some by inoculation, others by variolous effluvia, and 
some in both ways, but they all resisted it. " There is evidence that 
Jenner worked with this subject, encountering and overcoming ob- 
stacles and opposition on every hand, for over twenty years before he 
announced it to the world, and it is known that fully two years 
elapsed between the first vaccination and the publication of his paper. 
It was entitled an ' ' Inquiry into the Causes and Effects of the Vari- 
olse Vaccinae, a Disease discovered in some of the western counties of 
England, particularly Gloucestershire, and known by the name of 
Cow-Pox/' 1 Jenner lived to see all opposition overcome, while the 
procedure was at once adopted all over the world, and to receive 
universal honors and emoluments as the greatest benefactor of his 
kind. 

Cow-pox is an infectious disease which appears in dairies from 
time to time, often at wide intervals of both time and space, and 
shows itself first in some particular cow, usually a young cow, a 
heifer in her first milk. It never appears first in other cattle than 
milk cows, and never shows itself elsewhere than on the teats or at 
adjoining parts of the bag, as they may be infected by direct pressure. 
It appears in the form of scattered papules, which in the course of a 
1 London, 1798, quarto; 1800, octavo; 1801, octavo. 



VACCINATION. 235 

few days show fluid at their apices, to become transformed into dis- 
tinct vesicles. These vesicles are broken by the hands of the milkers, 
and the disease is thus disseminated in the course of a few weeks, 
sometimes months, throughout the entire dairy. 

It is a matter of secondary importance, so far as the protective 
efficacy of the virus is concerned, whether so-called animal or human 
lymph be employed in vaccinating, for it is the same virus in every 
case. Animal lymph ' ' takes " slower and harder, but compensates 
for these objections by freedom from any possible infection with 
tuberculosis, syphilis, or other disease, excepting possibly erysipelas. 

Bacteriology. — Vaccinia alone would seem to offer all the condi- 
tions essential to easy separation of characteristic elements, but the 
numerous attempts in this direction have not yet been rewarded with 
success. The efforts of Schulz resulted rather in the conversion of 
active into useless matter. Garre was not able to induce vaccinia 
with the micrococcus he considered peculiar to the affection, and 
the efforts of Tenholdt and Dougall were not more successful with 
the micrococci isolated and cultivated from lymph of proven po- 
tency. 

The proof of the degree of protection is seen at a glance by ob- 
servation of statistics in countries and cities where they are most ac- 
curately kept. Thus in Sweden the mortality from small-pox in the 
twenty-four years before the introduction of vaccinia (1801) was 
2,050 per million annually; after vaccination, 158 per million. Drys- 
dale says of Berlin that the mortality in that city during the epidemic 
of 1872-73 rose to 243 and 262 respectively per one hundred thousand 
inhabitants. Thereupon vaccination in the first year of life was 
made compulsory, and re vaccination in the twelfth year of life, with 
the result that in the first year of enforcement (1875) the mortality 
fell to 3.6 per one hundred thousand, to 3.1 in the year 1876, to 0.3 in 
1877, and so on for succeeding years down to 1883 with an average 
of 1.7 per one hundred thousand. The nearly absolute protection of 
vaccination is shown again by comparison of cities in which vaccina- 
tion and revaccination are obligatory and optional. Thus, according 
to the Berlin Health Office, the mortality of small-pox per one hun- 
dred thousand inhabitants in 1888 was in Dresden 0, in. Berlin 0.07, 
in London 0.6, in Munich 0.75, in Hamburg 3.58, in Paris 9 0, in St. 
Petersburg 15.30, in Vienna 26.15, in Prague 55.49. Corbally re- 
ports that the vaccinated children of Sheffield, 1887-88, had, as com- 
pared with the unvaccinated children, a twenty- fold immunity from 
attack, and a four hundred and eighty fold security against death by 
small-pox. These facts render further statements superfluous, but a 
few points may be added from army life. Army statistics, on ac- 
count of accuracy, are especially valuable. Schulz shows that since 



236 



VACCINATION. 



the operation of the German law the annual average cases of small- 
pox per one hundred thousand was, in the army of Germany, 4. 94; of 
France, 169.72; of Austria, 374. During the Franco-German war 
(1870-71) the mortality of small-pox in the unvaccinated French 
army was 23,469, while that of the vaccinated German army was but 
261. As stated elsewhere, there has been reported but a single case 
of death from small-pox in the German army since 1874. 

The immunity conferred by vaccination does not, as Jenner 



OEATHS FROM 

SMALL-POX 

PER IOOO OP THE 

POPULATION 

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MORTALITY FROM SMALL-POX IN BOSTON. 

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Fig. 135. 



hoped, last for life. Therefore revaccination becomes a necessity 
after a lapse of years. The best proof of this necessity is furnished 
the fact that revaccination "takes" as a rule ; thus among the 



in 



soldiers of Prussia, Russia, and Denmark in 50 to 70 per cent of cases. 
Heim found in five years but one case of varioloid among 14,384 re- 
vaccinated soldiers and but one case among 3,000 civilians, small-pox 
meanwhile prevailing in three hundred and forty-four places in which 
these people lived. 



VACCINATION. 



237 



Moreover, the number of extensive epidemics have diminished 
from 71.4 per century previous to vaccination, increased to 84 during 
inoculation, to 24 since vaccination. 

Protection begins on the fourth day after the introduction of the 
virus, and is perfect on the ninth day. The degree of protection, in- 
dependent of revaccination, is determined to considerable extent by 
the success of the operation and by the quantity of matter intro- 
duced — i.e., by the number of places vaccinated. Thus, according 
to Marson, the average mortality of small-pox among all vaccinated 
persons is 5.24 per cent, while that of individuals showing perfect 
cicatrices is about one-half of one percent. In 6,000 cases of small- 

DEATHS FROM SMALL-POX IN BERLIN AND VIENNA DURING THE YEARS 1870 TO 1886. COMPULSORY 
VACCINATION LAW ENACTED IN BERLIN IN 1874. OF EVERY 100,000 INHABITANTS THERE 



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pox after vaccination observed by Simon in twenty-five years, the 
percentage of death among individuals without cicatrices was 21.75 
per cent ; with one indefinite cicatrix, 12 per cent ; with one typical 
cicatrix, 4.25 per cent; with two cicatrices, 4 percent; with three 
cicatrices, 3.25 per cent ; with four or more cicatrices, 3 per cent. 
This fact finds additional proof in the observation that the pro- 
tection of vaccination, however great, is not so thorough and sus- 
tained as that offered by an attack of small-pox itself, whether con- 
tracted by ordinary exposure or by inoculation. Vaccination, and 
revaccination once or twice in later life, as at puberty and maturity, 
protect for life absolutely. The exact protection by single vaccina- 
tion cannot be definitely established. It varies in different cases. 
If revaccination "takes," the individual was certainly liable to take 
small-pox. The operation is so simple and inexpensive as to justify 
its practice at stated intervals, and inasmuch as no case of small- 



238 VACCINATION. 

pox contracted within seven years — twelve in Germany, according to 
the report of the Health Office — after a successful vaccination stands 
upon authentic record, this period may be put down as the proper 
interval for absolute protection, with the injunction in all cases that 
revaccination be performed with every exposure seven years after the 
last successful vaccination. 

Objections. — As already stated, it is a matter of indifference 
whether use be made of human or bovine lymph. Objection was 
raised against human lymph on the ground that it had undergone 
degradation. Hebra declared, however, that the lymph used in 
Vienna produced the same effect as when first introduced. Chapin, 
of Rhode Island, made the same observation of matter that had been 
employed for twenty-six years upon nearly forty-seven thousand 
persons. With proper care in the selection and preservation of 
lymph, it undergoes no diminution in potency and protection. 

But a valid objection to the use of human lymph is the possibility 
of the conveyance of other disease. Thus it has been asserted that 
tuberculosis, syphilis, and erysipelas have been transmitted in 
this way. The possibility of introducing these diseases with vac- 
cination is unquestioned, though, as a matter of fact, tuberculosis 
has never been transmitted in this way. The few apparent cases 
recorded meet with truer interpretation as localizations of bacilli 
tuberculosis previously latent in lymphatic glands (scrofula). As to 
syphilis there is no doubt. It is admitted that the disease has been 
introduced in this way by the use of virus from syphilitic infants. 
It was for a long time maintained that this disease could not be thus 
conveyed unless blood, pus, or matter other than the pure lymph 
had been introduced with the lymph itself. It is, however, now 
determined that the virus of syphilis may be conveyed with the 
pure lymph of vaccinia virus. Robert Cory, chief of the Natural 
Vaccine Establishment, England, settled this question with a self- 
sacrifice that finds but too frequent following in other fields. He 
selected only ^jfear, pure lymph from children who showed unmis- 
takable evidence of the disease in the stage of active eruption. With 
this lymph he vaccinated himself on several occasions. After re- 
peated failures he succeeded in producing in the course of three 
weeks, after a last inoculation, a distinct eruption, followed in irre- 
gular course by sore throat and other unmistakable evidences of 
syphilis (Plant). The difficulty as well as the possibility of trans- 
mitting syphilis in this way is proven in this experiment. The 
smallest precaution as to the selection of subjects suffices to procure 
protection against this disaster. The transmission of syphilis is 
easily avoidable by taking matter only from healthy children at 
least six months old, the ultimate limit of "tardy" inherited syph- 



VACCINATION. 239 

ilis, and all possibility is absolutely excluded by the use of animal 
matter, as syphilis is an exclusively human disease. 

Erysipelas (streptococcus) may be introduced with vaccination, 
or may fall later upon the broken surface. The accident is rare in 
any event, occurring in the practice of the author but twice in 
twenty-five years, 'but has been sufficiently frequent during the pre- 
valence of an epidemic of erysipelas — as in Boston, 1854 — to justify 
the suspension or postponement of vaccination. 

Time and Technique. — Vaccination should be done at the age of 
three to six months, or, in the presence of an epidemic, at any time, 
even at birth. In case of failure the operation should be repeated at 
intervals until it is crowned with complete success. Re vaccination 
at stated intervals— at puberty, maturity, or at any time during an 
epidemic — robs the question of the value of the kind of virus, or the 
number of vaccinations at one time, of practical interest. 

Points of selection for the operation are about the insertion of the 
deltoid or the junction of the heads of the gastrocnemius muscles. 
In protection against future carelessness regarding revaccination the 




I 1 

Fig. 137. Fig. 138. 

Fig. 137.— Strokes and cross-strokes for vaccination. 
Fig. 138.— Bone point for vaccine virus. 

matter may be introduced at three places, at the angles of a triangle 
(horizontal insertions at the shoulders permit concealment by a nar- 
row sleeve), at least half an inch distant from each other. Six or 
eight parallel tracings or strokes, with as many cross-strokes, with 
the point of a knife, so light as to expose the superficial lymphatics 
and draw little or no blood, afford the best wound, upon which the 
moistened bone surfaces may be gently rubbed. 

Susceptibility is universal. There is no such thing as insuscep- 
tibility to vaccination. Seaton never saw it in more than nine 
thousand cases at the Black Briars National Vaccine Station. Cory 
confirms this statement with reference later to bovine lymph, and 
Robertson declares that so-called constitutional insusceptibility is 
usually a confession on the part of the operator that he has not 
ascertained the cause of his failures. 

Pathology. — The true vaccination shows all the characteristics of 
a single typical small-pox pustule. At the end of forty-eight hours 
the surface of insertion is marked by slight redness and swelling to 
the size of a large papule, upon the summit of which develops, by 



240 VARICELLA. 

the third or fourth day, a small vesicle filled with a clear fluid. 
This vesicle is a reticulated sac, the puncture of which, as for the 
collection of lymph, discharges by slow oozing its fluid contents. It 
reaches its maximum size by the seventh or eighth day, at wLich 
time it is umbilicated and surrounded by a ring of inflamed tissue — 
the areola — which continues to enlarge for two days, to attain in full 
development a diameter of one to three inches. The contents of the 
vesicle now begin to grow somewhat opaque (pus), to present the 
appearance on its inflamed base quaintly described by Jenner as 
"the pearl on the rose/' The areola is the evidence of a successful 
vaccination. By the tenth day the serum is changed into pus ; the 
vesicle has become opaque and yellow ; its centre shows inspissation 
in the form of a crust, which, by the fourteenth day, extends to 
convert the whole pustule into a hard, dry mass. The crust falls 
spontaneously by the twentieth to twenty-fifth day, to leave, as a 
result of tissue destruction, a characteristic scar. The cicatrix of 
vaccinia is a more or less circular depression marked by minute pits 
and radiating lines. It should measure in its diameter fully one- 
third of an inch. Red or pink at first, its color gradually fades to 
the bleached appearance of cicatricial tissue, to remain as a mark for 
life, or to gradually disappear, in the course of adolescence, to the 
faintest trace. However pronounced, a cicatrix, it is needless to 
state, is evidence only of destruction of tissue, not of permanent 
protection against small-pox. The writer recalls a malignant case of 
purpura variolosa in a young woman whose arms were marked by 
typical cicatrices, relics of successful vaccination in early childhood. 
Slight fever, fretfulness, headache, insomnia, restlessness, disturb- 
ances of digestion, lymphangitis (as marked by swelling of the axillary 
glands), may be present for a few days about the time of maturation 
of the vesicle, to subside rapidly during the period of incrustation. 
More extensive inflammation, dermatitis, or ulceration indicate mixed 
infection. The constitutional signs are mildest in infancy, and in- 
crease in severity with advancing years. 

Delay in the appearance of the vesicle, even to the end of a week, 
does not preclude success, provided the subsequent phenomena 
appear in course. Accelerated, abortive, so-called "spurious" vac- 
cinations differ in various ways, and furnish only partial, limited, or 
no protection. 

VARICELLA. 

Varicella, or varicelke, diminutive of varus, pimple, pock; chicken 
(French, chiche; Latin, cicer, insignificant) pocks or pox; water 
pock, wind pox; variola notha, spuria, false pox. — A trivial, acute in- 
fection of childhood, distinguished by a long period of incubation, 



VARICELLA. 241 

absence of prodromata, slight fever, a vesicular eruption varied in 
size and short in duration, as a rule without complications or 
sequelae. 

History. — Chicken-pox met its first description under the term 
crystalli by the Italian anatomists, Ignassias (1575), Guido Guidi 
(Latin, Yidus Yidius, as in the Yidian canal) (1585), and received its 
present unfortunate name from Yogel (1764). 

Fuller (1730) and Heberden (1767) made the first attempts to 
separate it from variola (varioloid), with which it had been hitherto 
confounded, and has been since by many authors (Hebra, Thompson) 
"with inconceivable persistence" (Thomas) — a mistake which re- 
sulted in complete confusion regarding the nature of both affections, 
and in reproach and disrepute of vaccination in its early history. 

The recognition of the fact that an attack of one secures future 
immunity from itself, but does not protect against the other, finally 
led to a distinct separation of the two diseases. Confirmation of this 
view was also obtained in the fact, as stated, that vaccinia does 
not prevent varicella, nor varicella vaccinia. Czakert, after three 
failures in the ordinary way, succeeded in vaccinating a boy, set. 
four, by introducing lymph into the interior of vesicles during an 
attack of varicella. 

Etiology. — Yaricella appears in sporadic and endemic, rarely 
epidemic, form, but epidemics never assume the range nor show the 
intervals of measles and small-pox. The disease does not die out 
entirely in large cities, but assumes somewhat of epidemic proportion 
once or twice a year on the opening of schools and kindergarten. It is 
confined exclusively to childhood (exceptions by Heberden, Gregory, 
and Seitz) up to the age of twelve, and is rare after ten. The short- 
lived contagious principle, probably from the vesicles, is believed to 
be inhaled (contagium halituosum). Infants are never born with 
chicken-pox. 

Bacteriology. — Inoculation experiments fail oftener than they 
succeed. Thus Hesse failed in eighty-seven, succeeded in causing 
a local eruption in seventeen and a general eruption in nine cases. 
Steiner claims to have succeeded eight times in ten trials, but was 
unable to propagate the disease from any case. Tenholdt found in 
the contents of vesicles a micrococcus which, inoculated in man, 
produced light redness and swelling like that of spurious vaccinia, 
and in one case a vesicle smaller than a sudamen, the affection 
remaining local. Pfeiffer found in fresh vesicles of thirty cases, 
without exception, a parasite (proteid) showing an amoeboid stage, a 
cystic stage, spore formation, and, after the development of numer- 
ous spores, a return to the amoeboid stage. Inoculation with con- 
tents of vesicles showed, three times in five days, a localized, circum- 
16 



242 VARICELLA. 

scribed varicellar exanthem, recurring scattered up to the eighth day. 
The parasite could not be cultivated upon any culture soil. 

Incubation varies from eight to seventeen days. 

Symptoms. — Prodromata, in some form of light malaise, occur 
only very exceptionally. In these rare cases they may assume 
prominence, and thus there may be headache, vomiting, high fever. 
Henoch once saw a case begin with convulsions. 

The disease is announced, as a rule, by the eruption, which shows 
itself in the form of spots of hyperemia, in the centre of which 
appear, in the course of a few hours, distinct but slightly elevated 
vesicles, which attain their greatest circumference in the course of 
three to twenty-four hours. The vesicles contain a clear, sticky 
serum of neutral or alkaline, never acid (as in sudamina) reaction, 
which fully distends the vesicle, and which exudes slowly, but not 
wholly, on puncture of the sac. The serum shows under the micro- 
scope a few pus cells, which, when exceptionally present in greater 
quantity, may make the vesicles appear like drops of wax. In lighter 
cases, without halo, the patient looks as if sprinkled with " drops of 
water" (Fagge). 

The eruption shows itself first upon the neck and chest (face, 
according to Thomas), to spread subsequently over the face and 
scalp, trunk and extremities, and shows itself always in successive 
crops, to the number of ten to fifty, or as many as two hundred to 
eight hundred, over the whole body, irregularly, never uniformly or 
at once. 

Vesicles vary also in size, usually from a pinhead to a pea, ex- 
ceptionally from a dime even to a dollar. These large vesicles are, 
however, always lax, never full, as is the case in the blebs of burns, 
blisters, and pemphigus. Distinct, isolate, and irregular elsewhere, 
they may show aggregation, like zoster, upon the extremities, but 
are very rarely confluent anywhere. They are very superficial, 
lifting only the upper layers of the epidermis, and penetrate to the 
rete Malpighi in only exceptional cases. Hence they but rarely show 
an umbilicus, and seldom leave a scar. Yet one or two scars are 
sometimes to be seen on the forehead, eyelid, or other part of the 
face, and a few such scars may produce as much deformity as a case 
of varioloid. In fact, the isolated chalk- white scars of the face in 
children are nearly always relics of varicella. 

The eruption may also show itself on various mucosce, as in the 
eyes, to produce conjunctivitis, keratitis; in the mouth and palate, 
to cause stomatitis; in the pharynx, to lead to more or less dysphagia, 
and induce, at times, swelling of the cervical glands; on the vulva and 
prepuce, where it may show itself as a string of vesicles on the inner 
aspect of the labia majora, or at the frsenum, to give rise to pain in 



VARICELLA. 243 

micturition. Vesicles which appear in the mouth, especially on the 
tongue, are readily broken, to show irregular, ragged abrasions, 
sometimes with aphtha- like surfaces. 

A slight rise of temperature, maximum 102° (exceptionally 106°, 
Heberden), with associate symptoms of fever, headache, insomnia, 
anorexia, nausea, etc., attends or may attend the eruption, to con- 
tinue with it two or three or, exceptionally, as long as five days. 
Defervescence is by crisis, without subsequent elevation or inter- 
ruption. Very light cases may show no fever at all. Relapse and 
recurrence are possible but not probable. 

Hutchinson described a grave form of varicella which occurred 
most commonly in weakly, ill-nourished children. The vesicles, in- 
stead of drying up in the ordinary way, grow blacker and larger, to 
present the appearance of round, black spots, of the diameter of an 
inch or more, scattered oyer the body. These crusts cover under- 
lying ulcers, which sometimes extend through the skin and subjacent 
muscular tissue. These cases are said to be very fatal. They may 
be attended with eye complications, irido-choroiditis and loss of 
sight. This variety must be exceedingly rare, as it is not mentioned 
by other authors, except Eustace Smith, who connects it with the 
curious tendency to gangrene seen in certain children. It is probably 
the result of a mixed infection, and has no more to do with genuine 
varicella than a coincident erysipelas or other dermatitis. Hemor- 
rhagic varicella has been observed (Andrew) as a special complica- 
tion in cachectic cases. Varicella may occur in connection with 
other infections, with measles, scarlet fever, diphtheria, pertussis, 
and even with variola (Sharkey). 

Diagnosis. — Inasmuch as varicella was so long, and is often yet, 
mistaken for variola (varioloid), the question of differential diagnosis 
assumes supreme importance. The diagnosis demands: 1. A knowl- 
edge of the existence of either disease in the vicinity or community, 
and a definite history of the pre-existence or absence of either in the 
individual, together with the period of the last successful vaccina- 
tion. 2. The age of the patient, as variola occurs at all ages, and 
varicella is almost confined to childhood. 3. Variola is preceded by 
prodromata — malaise, fever, headache, backache, sometimes by ini- 
tial rashes— and is attended by a characteristic eruption on the third 
day; varice]la announces itself with its eruption, without prodromata. 
The most anxious mothers seldom notice illness of any kind until the 
eruption appears. The physician is called to decipher the eruption. 
4. Varicella appears, as a rule, first upon the back, neck, and chest, 
or, if upon the face, irregularly over it, and irregularly over the body. 
Variola appears, as a rule, first upon the face, forehead, to extend 
over it regularly from above downward, thence to spread uniformly 



244 DIPHTHERIA. 

over the neck, chest, etc. 5. The superficial vesicles of variola con- 
tain only serum; the deeper-seated vesicles of variola, serum and, 
later, pus. 6. The eruption of variola is much more uniform in 
size; that of varicella varies greatly. 7. Varicella is rarely conflu- 
ent anywhere, and its vesicles are only exceptionally umbilicated. 
By the end of the third day spots of hyperemia, fully developed 
vesicles, and crusts may be perceived simultaneously and side by side 
in varicella, whereas the variations in. the age of the eruption would 
be observed only at points distant from each other in variola. 8. 
The eruption of varicella may be abundant anywhere over the body, 
the face, trunk, or extremities; the eruption of variola is most abun- 
dant upon the face and fingers. A thick eruption upon the fingers 
has often established the presence of variola. 9. Fever precedes by 
several days the eruption of variola, to fall with its appearance ; 
whereas fever occurs only with the eruption of varicella, to increase 
with its development. Variola shows in further course marked sec- 
ondary fever, absent in varicella. 

There are exceptions to all these rules, but they form m their en- 
semble almost unimpeachable evidence. The cases about which may 
still hover any doubt or uncertainty should be considered as variola 
to secure proper protection of others by vaccination. 

Prophylaxis and Treatment. — The mortality of varicella is prac- 
tically nil. Trousseau says no physician has ever seen a patient die 
of chicken-pox alone; yet, inasmuch as complications, fatal haemor- 
rhages, catarrhal pneumonia (Meigs and Pepper), nephritis (Hutch- 
inson and Henoch), have been recorded as coincidences or complica- 
tions, delicate children may be protected by removal from the area 
of infection, or isolation of patients in separate rooms. Patients 
should remain indoors, if not in bed, during the existence of the erup- 
tion, and should not be permitted to return to school until all signs of 
it have disappeared. Vesicles, more especially extensive vesicles or 
pustules on exposed surfaces, "should be treated with consideration to 
prevent or limit subsequent lesions. It is advisable to touch the sur- 
face of such vesicles with equal parts of carbolic acid and glycerin, 
to secure, if possible, speedy coagulation of their contents and de- 
struction of pus-producing micro-organisms. Where the eruption is 
unusually abundant, as on the face, the whole surface may be bathed 
in sublimate solutions 1 : 1000-5000, or washed with one-per-cent 
solutions of creolin. 

Other treatment is superfluous, or does not differ, if called for by 
complications, from that discussed with varioloid. 

DIPHTHERIA. 

Diphtheria (SicpOepa, leather, membrane), term diphtheritis first 



DIPHTHERIA. 245 

applied by Bretonneau (1821); angina maligna; German, Brciune, 
from pruna, glowing coal ; Spanish, garrotillo. — A grave, acute 
infection of the exposed mucosae, especially the fauces, pharynx/la- 
rynx, nose, exceptionally the vulva, vagina, uterus, palpebrse, pre- 
puce, anus, occasionally of any wound of the skin; characterized by 
the formation upon and in the tissues of the affected surface of a 
grayish-white membrane, tumefaction and pain in the throat, dys- 
phagia, enlargement of the lymphatic glands, general prostration, 
comparatively short though indefinite duration; complicated often 
with septic infection ; and followed at times by a paralysis peculiar to 
this disease. Diphtheria of the throat, which is alone discussed here, 
has a mortality equal to that of scarlet fever, measles, and typhoid 
fever combined. 

History. — The history of diphtheria is involved in inextricable 
confusion, from the fact that all kinds of sore throat, simple and ma- 
lignant, catarrhal and croupous, gangrenous, individual and epidem- 
ic, were differently styled by different authors up to the time of 
Bretonneau, who succeeded in disentangling diphtheria proper as a 
disease distinguished by the formation of a false membrane in the 
throat. That the ancient writers were familiar with the affection is 
recognized in a passage from Aretseus, who speaks of ulcers cov- 
ered with a quoclam concrete* humor e albo. 

Disregarding now the frequent allusions made to the anginas by 
the early writers, because always confounded with secondary or other 
affections, we read the first clear and certain account of the disease as 
it prevailed under the name garrotillo, in Seville, in 1583, to extend 
throughout Spain in 1583-1618, the year 1613 being characterized, 
from the frightful mortality, as the " anno de los garrotillos." The 
disease appears next unmistakably in Italy in 1610, while Portugal 
was visited but slightly in 1626. The first definite account of it in 
Holland and France occurs in 1745, in England in 1748, in Switzer- 
land and Germany in 1752; and in our own country, in New York 
in 1771, in our northern colonies in 1755, in Virginia in 1799. Diph- 
theria now nearly disappears from medical history from 1810 to 1840, 
with the exception of France, where it again showed itself in Lyons 
in 1810 and in Tours in 1818 to 1821, to fall under the observation 
of the eccentric but always original Bretonneau, who dissociated it, 
as stated, from other affections of the throat and distinguished it as 
a special disease. Bretonneau stoutly maintained that it was always 
a local process at first, with subsequent general infection. Later, in 
1825, he recommended alum in its treatment, made tracheotomy in 
grave cases of invasion of the larynx, and invented the double canula 
for this purpose. Trousseau, the pupil of Bretonneau, declared : "In 
diphtheria it is as in malignant pustule, in which malady, by making 






246 



DIPHTHERIA. 



a direct attack upon the local affection, we stop the progress of the 
general disease. ... So also it is in diphtheria: by energetically 
treating the local affection as soon as it shows itself, we arrest its 
progress and prevent the occurrence of ulterior symptoms." 

The new era of general dissemination or pandemic occurrence 
dates, according to Hirsch, from 1857-58, when the disease appeared 
in, or was carried to, remote parts of the earth, as India, China, 
Australia, Polynesia, Africa. It showed itself almost simultaneously 
in California and New York in 1 856, next in the Eastern States, then 
in the Middle, Southern, and Western States, reaching Oregon in 
1867. Our first accounts of" it date from Mexico in 1864; New- 
foundland in 1867 ; South Russia in 1872 to 1879, when it raged 
in villages to such extent that Kupffer says " the children disap- 
peared." 

Etiology. — Neither season, soil, nor social caste is directly con- 
cerned in the production or the spread 
of true diphtheria. The disease pre- 
vails in the most salubrious villages 
at times, sparing the marsh, passes the 
crowded tenements of the city to visit 
the palaces of the suburb, and shows 
itself at every season of the year. 

False membrane may be formed in 
the throat by various micro-organisms, 
especially by the Streptococcus pyoge- 
nes, but the true diphtheria is produced 
by a special bacillus discovered by Lof- 
tier in 1883. Klebs had previously 
seen the same structure among others in the false membrane of this 
disease, and had recognized it as one among other causes of the 
disease, so that the micro-organism is now known as the Klebs-Loffler 
bacillus. To Loffler is due tl^e credit of having first isolated it and 
experimented with it upon lower animals. 

Bacteriology. — The Bacillus diphtherise is about as long but 
is twice as thick as that of tuberculosis. It is always rounded 
at both ends, and is frequently knobbed, to present the appearance 
of dumbbells, by which name it is commonly known. It is im- 
mobile, shows no spores, has its optimum temperature at body heat, 
and stains perfectly with alkaline methylene blue. It thrives in 
most of the culture soils, best in blood serum, lives desiccated over 
one hundred days, and produces, when injected into the bodies of 
certain animals, definite symptoms and speedy death. Thus it de- 
velops in guinea-pigs, rabbits, chickens, and pigeons, at the seat of 
inoculation, a pseudo-membrane, in which it rapidly multiplies. 




Fig. 139 —Bacillus diphtheriae from 
blood serum (Sternberg). 



DIPHTHERIA. 247 

Frosch declares that he found it in the blood, brain, lungs, liver, 
spleen, kidneys, cervical and bronchial glands in man, and Abbott 
claims to have demonstrated it in the omentum after inoculation of 
the testicle of lower animals. Most of these animals succumb 
within a few days after its introduction into the tissues. Injected 
into the trachea of these animals, or engrafted upon a scratched con- 
junctiva or vagina, it develops the pseudo-membrane found in 
human croup. Paralysis follows in certain cases. 

Culture soils, filtered free of bacilli, produce, when injected, the 
same effect as soil containing bacilli (Kitasato). Diphtheria is 
therefore a local infection, by a bacillus whose toxalbumin produces 
the general effects (Welch and Abbott). This toxalbumin is very 
sensitive to heat. It perishes in a few minutes at 65 C.° All ob- 
servers encountered also other bacteria, especially strepto- and 
staphylococci, which penetrate the depths of the tissues and induce 
general infection. Thus develop varieties — mild, or secondary, or 
malignant, or gangrenous diphtherias. Cultures distinguish the 
various bacteria and establish the diagnosis in 
a doubtful case (Baginsky). --H- ' , 'j r . 

Animals may be rendered immune to diph- • • x - .."r- . ' •• ... 
theria by previous treatment with the peroxide • *\ "•,:' " ' •%• 
of hydrogen ; by inoculation with cultures sub- : ';* V/~ ..-.. '*- 
jected to heat, with the trichloride of iodine, m '*.C '•'.:•' 

with certain products of the bacillus itself, or FlG 140. -streptococcus 
with the fluid of pleural effusions which always and staphylococcus from 

» . -, , -1 . exudate. 

rorm m inoculated guinea-pigs. 

Symptoms. — After a period of incubation of three to five days 
an average typical case of diphtheria begins with a ch ill, or chilly 
sensations, attended with malaise, rise of temperature, more or 
less nervous unrest, and, in the course of the same day, distress in 
the throat. In lighter cases throat symptoms may alone direct 
attention to the character of the disease, while in more pronounced 
cases the general distress assumes such prominence that the practi- 
tioner is led to look into the throat only because he may find for it 
no adequate explanation elsewhere. Thus it may happen that the 
disease is not recognized until the third or fourth day, by which 
period valuable time for therapy is lost. 

It is characteristic of diphtheria to show objective signs in the 
throat very early in the history of the disease. Along with the com- 
plaints of dryness, burning and constriction, evident dysphagia 
and tenderness, there may be merely a more or less pronounced 
hyperemia about the tonsils, veil of the palate, or pharyngeal wall, 
to constitute the so-called catarrhal stage, in which the false mem, 
brane may be entirely absent. Such cases are readily mistaken for a 



2'48 DIPHTHERIA. 

simple catarrh, tonsillitis, or quinsy until complications or sequelae 
betray the true character of the disease. 

For the most part, however, there is little room for mistake. 
The false membrane shows itself early as flakes, spots, or streaks, 
not easily distinguished from pure mucus, upon the mucous surface ; 
white, filmy, or fleecy, easily detachable at first with the finger or 
handle of the spoon, to become in the course of a few days thicker, 
tougher, and darker in color, and to involve the mucous coat to such 
extent as to leave a raw, bleeding surface after forcible removal. 
The false membrane may remain localized, or may spread gradually 
or rapidly over the whole interior of the throat, to extend thence to 
the nose, Eustachian tube, larynx and bronchi, oesophagus, or, 
being detached by cough or processes of sloughing, may renew itself 
in former sites to indefinitely prolong the disease. 

Still later in the course of the disease, as a result of mixed infec- 
tion, the membrane may grow darker, grayish-black or absolutely 
black, become more friable and be detached in places to hang in 
festoons, or be insufflated with acts of respiration to excite violent 
cough or interfere directly with respiration. The peculiar and fetid 
odor of decomposition is now usually present ; the face is pallid, the 
pulse feeble or easily excited, and blood poisoning is marked by 
apathy and profound adynamia. 

With the extension of the disease deep into the tissues of the 
mucous membrane there is invasion of the submucous connective 
tissues, lymph ducts and glands, and interglandular connective tis- 
sue, so that individual glands, tender to pressure, may stand out 
prominently above the general surface of the neck, or the natural 
outlines of the neck be obliterated in a universal tumefaction. 

As in all the grave infections, parenchymatous changes may 
occur in the heart, liver, spleen, and kidneys, so that heart failures 
in the course of the disease, peri- and endocarditis with subsequent 
valve lesions, albuminuria with subsequent B right's disease, may 
attend the course, complicate * the progress, or protract the convales- 
cence, if they do not directly take life. 

The paralysis which occurs during, or much more frequently 
after, diphtheria is, as stated, in its course and character peculiar to 
this disease. It shows itself in about one-fourth of all cases which 
do not succumb to the attack. Rare in infancy, liability to it in- 
creases with years. It occurs alike in the strong and feeble, in mild 
as well as in severe cases, in diphtheria of other mucosae, or of 
wounds as well as of the throat. It has been observed in the throat 
as early as the second, more frequently at the fifth to the tenth day 
ef the disease, but as a rule not until the second or third week after 
the disease has run its course. It is regarded, hence, as a post-diph- 



DIPHTHERIA. 249 

theritic process, due in all probability to the delayed action of 
toxines upon peripheral nervous organs. Its mode of invasion and 
progress constitute peculiarities distinctive of diphtheritic paralysis. 
In the first place, it is ushered in at once without prodromata, usually 
in the midst of health, or that degree of it which is left in convales- 
cence from the attack proper. With very few exceptions it shows 
itself first in the palate, in difficulty of deglutition, and often of 
phonation. Fluids regurgitate through the nose, and the voice is 
altered. On inspection it is seen that the palate drops or is not lifted 
in pronouncing " ah/'" or the uvula is deflected. Gargling is impos- 
sible. The paralysis may extend to involve also the epiglottis, which 
ceases then to protect the larynx during deglutition, or more rarely 
to the pharynx to increase the dysphagia. There is often also 
paralysis of sensation, so that the veil of the palate may be manipu- 
lated without reflex action, or the pharynx may form a pouch in 
which food accumulates. - 

The paralysis next affects the intrinsic muscles of the eye. Far 
sight remains, but accommodation for near objects, as in reading, is 
decidedly interfered with. Yet the light reflex persists unaffected. 
Here the paralysis may cease, or in about one-half of cases the ex- 
tremities, the lower first, are affected with tingling, numbness, 
formication. More frequently motion alone is impaired, the legs are 
weak, there is early fatigue with a sense of heaviness or weight, 
the patient staggers occasionally or constantly, the gait limps. As 
in the throat and eye, the affection is usually bilateral, though one 
side may suffer sooner or more. Electric action, unimpaired at first, 
becomes feeble or absent to faradization. Knee jerk is always di- 
minished, then lost, from and even before any sign of paralysis 
proper — a phenomenon of very great diagnostic significance, and 
"part of a wider fact that the knee jerk is often lost after diphtheria 
(two-thirds of cases) in which no paralysis occurs" (Bernhardt). 
Paralysis of the intercostal muscles, diaphragm, and heart is fortu- 
nately very much more rare. Dyspnoea, vertigo, heart failures, with 
retarded, irregular, and intermittent pulse and fatal syncope, result 
from attack of these muscles. Impotence from affection of the 
sexual centres is not quite so rare in adult males. The bladder and 
rectum are very rarely involved. It is in this order that diphtheritic 
paralysis shows itself as a rule, though the natural sequence is often 
disturbed and " irregular waves of palsy seem to flow through the 
body"' (Gowers). 

Still another peculiarity of diphtheritic paralysis is its incomplete- 
ness. The paralysis is rarely absolute. It is, as a rule, more a 
weakness than a total loss of power. It is regarded as a polyneuritis 
and not as a central lesion. 



250 DIPHTHERIA. 

Diagnosis. — The points upon which the diagnosis of diphtheria 
rests are: 1. The prevalence of the disease. 2. The absence of a 
previous attack ; for the belief gains ground, contrary to previous 
opinion, that one attack secures future, at least temporary, immunity. 
Thoresen claims that in six hundred patients he never knew a second 
attack. He had the hardihood to quarter diphtheria patients in 
houses where children had suffered previously, and never saw a 
second attack. Contrary opinion is due to confusion with follicular 
angina. 3. Affection of both tonsils, with extension to the palate, 
etc. 4. Albuminuria. 5. Discharge of a thin, serous fluid from, or 
presence of false membrane in, the nose. 6. Contagiousness. 7. The 
bacillus, which is easiest cultivated to colonies (twenty-four hours) 
upon cooked white of egg. Tumefaction, lymphadenitis, and fever 
are not essential ; typical cases may show none of these signs. 

Diphtheria is distinguished from simple tonsillitis by its attack 
of others (en- or epidemic), false membrane, lymphadenitis, and gene- 
ral tumefaction, not present in tonsillitis; by the more profound pros- 
tration, adynamia, loss of knee jerk, and subsequent paralysis in 
diphtheria; from quinsy, which is epidemic tonsillitis, by the more 
pronounced inflammation and acute distress, greater swelling and 
dysphagia, with at times oedema of the uvula, palate, and glottis, ab- 
sence of false membrane, presence of knee jerk, and, notwithstanding 
the severity of the symptoms, more favorable course of quinsy. 

That a scarlatinal differs from true diphtheria is now determined 
by the researches of bacteriology. Clinically the affections differ as 
follows : The false membrane appears at once in diphtheria, later in 
the course, three to five days, of scarlatina; it shows itself in nearly all 
cases of diphtheria, but only in severe cases of scarlatina — viz., such 
as are marked by high fever, delirium, etc., at the start; it shows a 
preference, after the pharynx, for the larynx in diphtheria, and for 
the upper respiratory passages in scarlatina. In connection with it 
suppuration of the cervical glands and affections of the ear are fre- 
quent in scarlatina, rare in diphtheria. The interglandular connec- 
tive tissue is indurated in scarlatina and only cedematous in diphthe- 
ria. Paralysis, which is frequent in or after diphtheria, is almost 
unknown in scarlatina. On the other hand, nephritis, a frequent 
sequel of scarlatina, is very rare after diphtheria. Lastly, treatment 
has much less effect upon the membrane of scarlatina. Hence it is 
proposed by clinicians (Henock, Filatow) to abandon the use of the 
term diphtheritic in scarlet fever, and to designate such cases as ma- 
lignant scarlatinal anginas. 

The prognosis of diphtheria is always grave on account of liabil- 
ity to heart failure, to sepsis (from mixed infection), and to extension 
to the larynx (croup). All these dangers are lessened or prevented by 
jugulation of the disease by energetic local treatment at the start. 



DIPHTHERIA. 251 

Statistics, which date from the time when the disease was believed to 
be constitutional with a local expression, are valueless in determina- 
tion of its gravity. Practitioners, thoroughly convinced of the local 
origin of diphtheria, do not fear it as they do scarlatina. It must be 
stated, however, that the amount or extent of the false membrane is 
no gauge of the gravity of the disease. Cases with throats covered 
as if with a layer of thick white paint often run a mild, short course, 
while the gravest symptoms — adynamia, heart failure, syncope — 
may occur in cases in which the membrane is so scant as to embarrass 
diagnosis. The character of the cause, whether the Loffler bacillus 
or the streptococcus, may make the difference. The gravity of the 
disease is rather a question of absorption than deposit, and the dan- 
ger is determined by the penetrability of the barrier which the tissues 
interpose. This is a condition which may not be discovered by sim- 
ple inspection. It reveals itself only in its effects. Profound adyna- 
mia, a feeble pulse, mixed infection, extension into the nose where it 
cannot be reached, suppuration, gangrene, make the prognosis very 
grave. The paralyses of diphtheria generally subside spontaneously 
in from three weeks to three months, and may be much abridged 
with appropriate treatment. 

Prophylaxis consists in isolation of the patient, thorough ventila- 
tion of the sick-room, and utmost cleanliness. The weaker antimy- 
cotic gargles mentioned in treatment may be used by others in the 
house. A child should not return to school for forty days. 

Treatment. — From what has been stated it is obvious that the 
true treatment of diphtheria must secure or attempt the eradication 
of the membrane which contains the germs of the disease. This 
treatment must be introduced at once, or so soon as the diagnosis is 
made. A dubious diagnosis justifies it, inasmuch as under no cir- 
cumstances can it do harm. What particular agent is employed is 
probably a matter of indifference, so that it be powerful enough to 
accomplish the object. Bretonneau used fuming hydrochloric acid.. 
Carbolic acid, corrosive sublimate, creosote, andcreolin each have their 
advocates. The author prefers above every other agent the subsul- 
phateof iron, as it not only destroys all micro-organisms which it may 
reach, but by its powerful astringent action interposes a barrier be- 
tween them or their products and the blood, and thus prevents the 
absorption which produces the so-called constitutional signs. The 
subsulphate is preferable to the tersulphate, on account of its greater 
astringency; and to the perchloride, which is much more astringent 
because it is much less irritant. 

The remedy is applied best by means of a cotton-wrapped sound, 
the end of which is immersed in the undiluted solution and pressed 
on withdrawal against the neck of the bottle, that the fluid may not 



252 DIPHTHERIA. 

drop into the larynx, and the false membrane is touched or the sur- 
face painted, under a good light, with the deftness and dexterity of 
an artist in touching a canvas. One application a day will suffice 
in an average, two in an aggravated case. It is generally well 
borne, exciting but little cough and expectoration, both of which 
are, however, favorable for the dislodgment of the membrane. 
Retching and vomiting sometimes follow — processes which also facil- 
itate the discharge of the membrane and stimulate the patient out 
of the apathy and adynamia characteristic of grave cases. 

Inhalations of steam from a steam atomizer, as hot as can be 
borne, are also of great value, if practised repeatedly throughout the 
day and night. They accomplish more in the dissolution of mem- 
brane and disinfection of the throat than any chemical solvents, 
lime water, lactic acid, pepsin, papayotin, etc., and the various dis- 
infecting gargles, etc., all of which are useless unless inhaled or 
applied more or less continuously, which is almost impracticable. 
The insufflation of yellow oxide ointment gr. v.- 3 ss. vaseline into 
the nose, two or three times a day, keeps the nasal passages moist 
and free, and adds much to the comfort of the patient. Sprays of 
fresh, pure peroxide of hydrogen are more efficacious in this regard 
than any other agents. Loffler recommended very deep gargling 
with sublimate solution 1 : 1,000, or carbolic acid three per cent 
dissolved in alcohol thirty per cent, or carbol five per cent, or bro- 
mine two per cent, or chlorine one per cent solutions. In the first 
stage of the disease, when the membrane is very thin, or in prophy- 
laxis, Loffler prefers weaker solutions, as of sublimate 1 : 10,000 or 
15,000, or, for its more agreeable taste, the cyanide 1 : 8,000-10,000, 
with introduction into the nose of toluol, which will diffuse itself 
throughout the nasal tract. 

The general symptoms are best met with alcohol, which, in its 
direct effects upon the heart as a cardiac stimulant, best obviates the 
danger of heart failure. Digitalis, preferably in infusion, 3 i.- 3 ss. 
every two to four hours, may become a necessity in protracted 
cases. Nitroglycerin acts quickly and does not at all irritate the 
stomach. A cup of strong, black coffee, with a tea- to a tablespoon- 
ful of cognac, is a quick though more temporary restorative. Sub- 
cutaneous injections of alcohol, ether, camphor, musk, may be 
necessary to bridge a case over an impending or actual collapse. In 
most cases a bold local treatment, by putting a stop to further in- 
fection, will often rescue a case from the profoundest prostration, 
and put a new and more favorable phase upon the disease in the 
course of a few hours. 

Paralysis is best treated by faradization and nitrate of strychnia 
gr. -j-J-jj- subcutaneously. 



CROUP. 253 



CROUP. 



Croup (old Scotch, croops ; Danish, hrop ; old Dutch, hrof and 
geroef; German, Geruf, cry, crow). — The crowing, stridulous sound 
of inspiration through an occluded glottis, as by spasm, false croup, 
laryngismus stridulus, or by false membrane, true croup, membra- 
nous croup. 

True croup, in the majority of cases, is diphtheria of the larynx. 
What features of difference it may show depend upon its localization 
and the rapidity with which it ends life by suffocation. Croup is, 
therefore, a disease which adds to the dangers of diphtheria a me- 
chanical obstacle to respiration. Croup may also exceptionally de- 
velop in connection with, or as a sequel to, other infections — measles, 
scarlatina, pertussis, rotheln, variola, typhoid fever, etc. — or in still 
more exceptional cases from mere catarrhal inflammation, or most 
exceptionally from chemical or mechanical irritation. 

History. — Dyspnoea and dysphagia from throat disease were all 
included under the term cynanche (angina) by the old Greek writerSj 
and laryngotomy (first by Asclepiades, 100 A.c.) was not infrequently 
resorted to in relief of suffocation. Galen certainly refers to a case 
of croup in an adolescent " qui tussicando tunicam crassam visco- 
samque exspuerat." Baillou, Paris (1576), describes cases secondaiy 
to measles and pertussis, and Van Hilden (1641), Ettmiiller (1G85), 
Patrick Blair (1718), who is credited with the first adoption of the 
popular word "croops" into medicine, mention cases under the term 
" catarrhus suffocativus," which included also a]] kinds of diseases of 
the pharynx and larynx. It is, however, to Francis Home, of Edin- 
burgh (1765), that we are by universal consent indebted for the first 
distinct identification and isolation of true croup. Home published 
his conclusions, based upon a wide and keen observation, in a short 
tract of sixty pages entitled ' ' An Inquiry into the Nature, Cause, 
and Cure of the Croup." Home looked upon the disease as primary 
in the larynx, and ascribed its symptoms to the presence of a mem- 
brane which he found in the trachea in all his post-mortem obser- 
vations. Cheyne (1801), in an essay on " Cynanche Trachealis, or 
Croup," confirmed these views, which now prevailed undisturbed up 
to the time of Bretonneau (1821), who first advocated the identity of 
croup with diphtheria. 

Etiology. — Croup occurs occasionally also as a complication, 
sometimes a fatal complication, of measles. It is more rarely seen in 
the course of, or as a sequel to, scarlatina; still more rarely after 
typhoid fever. Croup may occur entirely independent of any infec- 
tious disease. Bretonneau himself recognized the possibility of the 
production of croup by the application of irritants, as by cantharides. 



254 CROUP. 

Oertel, Trendelenberg, Schwenninger were able to produce false mem- 
brane in animals by various mechanical and chemical irritants. It 
has long been known that false membrane may be formed in the 
larynx in consequence of the inhalation of hot steam. Heubner pro- 
duced false membrane in the larynx by interruptions of the circula- 
tion. Most interesting are the observations of Kreissig, who saw 
false membrane formed in the larynx of animals subjected to high 
temperature. Heat and dryness are at times sufficient causes for 
the formation of false membrane. Inhalation of irritant gases — 
ammonia, chlorine, bromine, fuming mineral acids — will also produce 
false membrane in the throat. 

These constitute the cases of so-called primary croup. It is un- 
deniable that such cases do occur. They constitute, however, the 
small minority of cases of croup. In these cases the cause is demon- 
strable, and the lesion of tissue or false membrane which forms 
distinguishes itself by remaining circumscribed. These are the cases 
in which the disease remains more strictly confined to the larynx. 
They differ, therefore, radically from the cases produced by infec- 
tious matter, whose nature it is to spread. It remains, therefore, 
true that croup, in the vast majority of cases, is diphtheria of the 
larynx. 

The disease attacks by preference children between the ages of 
two and seven. Cases of attack in infancy, as by Bouchut at the 
age of eight days, Monti fourteen days, are very great exceptions. 
Liability begins to diminish at five and becomes almost annulled at 
seven. Exceptionally cases have been reported even late in life. 
Diphtheritic croup does not remain confined to the larynx, as a rule, 
but extends in most cases to involve the trachea and bronchial tubes. 
Steinert saw four cases of croup ascend from the trachea to the 
larynx; and of fifty-five cases, five only were confined to the larynx, 
nineteen involved also the trachea, and thirty-one extended to the 
bronchial tubes. In the epidemic at Konigsberg, Bohn found in 
twenty autopsies the trachea affected sixteen times, the bronchi only 
three times. Bretonneau in thirty-two cases found the bronchial 
tubes unaffected only once. In one hundred and forty-four autopsies 
after croup, Peter found in the bronchial tubes catarrh forty-four 
times, croup thirty-two times, in eleven no lesion at all. 

Symptoms. — Croup sets in very insidiously, and may not be dis- 
tinguished at the start from an ordinary catarrh localized in the 
larynx. There may or may not be more or less malaise, f retf ulness, 
irritability, irritation about the throat, but in the course of a day or 
two the inflammation of the throat takes on that specific character 
which distinguishes itself by the alteration of the voice, the charac- 
ter of the cough, and the difficulty of breathing. The voice becomes 



CROUP. 255 

husky, the cough more guttural, the breathing more difficult. As 
a rule the child wakens in the night with the symptoms of marked 
croup. Probably at the very start the voice is lost. The child can- 
not speak above a whisper. It tosses about the bed, exhausted, agi- 
tated, moves its head about first on one side, then on the other, seek- 
ing by change of posture to obtain relief. The breath is longer 
drawn, occasionally sighing; the auxiliary muscles of respiration 
are called into play. The mouth is open; there is play of the nostrils, 
evident straining to force a full breath. Under all these efforts, in 
the course of time, the breathing becomes somewhat easier. The 
child, exhausted, sinks to sleep, to be awakened often in the course of 
the night with a repetition of the same scene. The patient is no, or 
but little, better in the morning. There are more or less distinct 
remissions, but there is no real relief. The attack repeats itself seve- 
ral times during the day, and by the following night becomes dis- 
tinctly intensified. The child is now wholly unable to sleep. The 
efforts at breathing become more strained and more painful to see. 
The face is flushed, the eyes glisten with a wild anxiety. The child 
clutches its throat, as if to tear an opening into the larynx, seizes the 
bedclothes, frantically tears the paper from the wall, shows mania, 
and finally sinks back exhausted, sometimes actually to suffocate in 
the attack, oftener to secure a comparative rest after the final en- 
trance of a small quantity of air. Soon now ensues the stage of car- 
bonic-acid poisoning. The face becomes pallid, cold, and blue, the 
surface is covered with a clammy sweat, the hot maniacal struggle 
ceases, the spirit is broken, the child lies apathetic, seemingly indiffer- 
ent. Respiration is more shallow and superficial. The intercostal 
spaces, the jugulum, epigastrium, supraclavicular regions, no longer 
retract or sink in with each act of inspiration. Sopor sets in, which 
deepens into stupor, coma, death. But in a minority of cases, at the 
height of the stage of struggle, quantities of false membrane may be 
ejected, casts of the larynx or the trachea, or even of the bronchial 
tubes, with such temporary relief at times as to give rise to the illu- 
sory belief in recovery. The membrane forms again, however, in 
the course of a few hours. An entire cast may reform in five or 
seven hours, to renew the same picture of distress. 

As a rule not much is to be seen in the throat — hypersemia, 
swelling, occasional flakes or films or masses of false membrane about 
the fauces or glottis, or in the larynx itself. What is especially to be 
remarked in the larynx is the swelling and occlusion of its orifice. 
Pieniazek finds the cause of the dyspnoea to be not so much the de- 
posit of false membrane as the fixation of the vocal cords or bands 
by reason of the exudation of intense inflammation. The arytenoid 
cartilages lose their play of motion, becoming, as it were, solid, an- 



256 CROUP. 

chylotic. Hence the dyspnoea; hence also the character of the cough 
and the alteration of the voice. 

Duration. — Croup is sometimes divided into stages of catarrh, 
stenosis, and collapse. The first stage lasts from one to ten, on the 
average three, days ; the second one-half to seven, on the average 
three, days ; the third one-half to two, on the average one, day. 
Thus the disease may run its whole course in two days, or protract 
itself over two weeks, but most cases scarcely occupy more than 
one week. 

Diagnosis. — Croup is diagnosticated by the catarrh of the larynx; 
by the laryngismus and loss of voice; by the peculiar character of the 
cough (Trousseau likens it, happily, to the sound of the bark of a 
puppy dog at a distance) ; by the dyspnoea with its long-drawn, aud- 
ible, stridulous inspiration ; by the play of the auxiliary muscles of 
respiration; by the retractions of the intercostal spaces ; and by the 
false membrane. 

True must be separated from false croup, laryngismus stridulus, 
which attacks for the most part infants brought up in close, hot, ill- 
ventilated apartments, hence children of the wealthy, coddled, pam- 
pered, over-protected rich oftener than the. children of the more 
.exposed poor. False croup may rest at times also upon a light 
catarrh. The child goes to bed, however, comparatively well, and is 
awakened suddenly in the night with the same terrible struggle for 
air. It shows the same distress as true croup, even more intense at 
the start, but subsides more quickly and completely, with, if it is to 
recur, much more distinct intermissions, and yields readily to simple 
treatment. It occurs again and again in the history of the child, 
whereas true croup occurs but once. There is, of course, no mem- 
brane in false croup. 

(Edema of the glottis occurs, in the great majority of cases, in 
adolescence or maturity, and in the course of laryngitis or some out- 
side disease, as of the heart 6r kidney. It is often associated with 
oedema, visible oedema, of the palate and fauces. The uvula itself is 
often affected. The condition may be seen at times with the naked 
eye, and felt frequently with the finger. 

Retropharyngeal abscess occurs, in a great majority of cases, in 
children in early infancy. It develops more insidiously than croup, 
and reveals itself sometimes to inspection, more frequently to palpa- 
tion, as a soft, fluctuating tumor on the posterior pharyngeal wall. 
Abscesses, after infancy, occur next most frequently in youth, in 
consequence of caries of the spine, with the history of exposure to in- 
fection by tuberculosis or with evident depots elsewhere. 

The prognosis of croup is intensely grave. . The child succumbs 
for the most part to direct suffocation, carbonic-acid poisoning, as- 



croup. 257 

phyxiation, or, surviving this danger, perishes later from blood 
poisoning in consequence of absorption, as in other cases of diphthe- 
ria. Operations for the relief of stenosis have, however, considerably 
ameliorated the mortality statistics. Cases left to themselves have a 
mortality, as a rule, of sixty to seventy per cent. Recoveries are the 
exceptions. Death is the rule. 

Treatment. — Internal medication has over the false membrane of 
croup no control. Emetics may dislodge loose fragments, or more 
especially relax spasm to give temporary relief, but for the most part 
they add their OAvn depression to that of the disease and are not to 
be recommended. Where for any reason they may be administered, 
selection should be made of the milder drugs, as of the subsulphate of 
mercury gr. iij.-v., or ipecac gr. xv., or apomorphia gr. T ^, which 
has the double advantage that it does not depress and may be ad- 
ministered subcutaneously. These are emetics and expectorants to 
be selected, but in no case" to be continuously administered. Local 
applications, gargles, etc. , are useless, because they may not reach 
the disease, or under any circumstances remain longer than a few 
seconds in contact with it. 

Benefit is always to be derived from the inhalation of steam, 
which may be conveyed to the bed under a tent improvised from the 
bedclothing, from a kettle on the fire, or, better, by means of a steam 
atomizer, to which additional solvent properties may be given by the 
use of bicarbonate of soda, lime water, lactic acid, etc. Papayotin 
may be applied in solution with a brush. Nothing radical may, 
however, be expected of any such treatment. Nor may drugs fur- 
nish any substantial relief until they may be applied in concentrated 
form to the interior of the larynx itself after tracheotomy. The 
application of carbolic acid, corrosive sublimate, solution of the sub- 
sulphate of iron, directed to the interior of the larynx after laying it 
open, is a question of the near future. At the present time the only 
relief to be expected in a case of croup comes from surgery. The 
obstacle in the throat is to be overcome either by intubation or 
tracheotomy. Intubation is a simple operation, which proves effec- 
tual in nearly forty per cent of all cases; most effectual, of course, in 
cases more circumscribed or more strictly confined to the larynx. 
The operation requires but little practice or skill, and does no harm 
should it fail to do any good. Moreover, it in no way interferes 
with the more radical operation of tracheotomy. Tracheotomy 
itself has been recently much simplified. It is an operation per se 
devoid of danger. It is performed now for the most part bloodlessly. 
Tracheotomy rescues about thirty-five per cent of all cases, thirteen 
per cent of diphtheritic, and sixty per cent of non-diphtheritic croup 
— a percentage which would be increased if . the operation could be 
17 



258 QUINSY. 

done as soon as the first signs of stenosis set in. Both operations 
have saved children who have actually ceased to breathe, so that 
it is never too late to try either or both. 

QUINSY. 

Quinsy is an anglicization of the Greek cynanche ; Latin, an- 
gina (sore throat); limited in our day to epidemic tonsillitis. It is 
an acute, probably contagious infection of the fauces, pharynx, and 
tonsils. 

Etiology. — The disease prevails most frequently during the sea- 
sons of fall and winter. It spares the extremes of life, to show itself 
between the ages of fifteen and thirty. There is a marked difference 
in different people in susceptibility to this affection, in that certain 
individuals suffer repeated attacks. Yet a single sharp attack con- 
fers immunity for at least a year. 

Symptoms. — Quinsy distinguishes itself by the severity of its 
symptoms, which are out of all proportion to the gravity of the dis- 
ease. It announces itself after an indefinite and unestablished period 
of incubation, with more or less sharp chill, attended by fever, 
anorexia, at times even nausea, pain in the back and limbs, head- 
ache, and pretty profound prostration. Gastric distress is more or 
less pronounced. There is a heavy coat upon the tongue, at times 
distinct nausea, and in younger individuals occasionally vomiting. 
The fever is high; the temperature advances, on an average, to 103°, 
and it may run up to 105° at the onset or at any time in the course 
of the disease. It is plain to see that an individual affected with 
quinsy is a sick man. The local manifestations are pronounced. 
The patient complains at once of a sore throat, which shows itself 
also in difficulty of deglutition. The veil of the palate, the uvula, 
both tonsils, the wall of the pharynx, are markedly hypersemic and 
swollen. The tonsils project as globular, shining masses into the 
throat, to such an extent often as to touch, sometimes to make such 
contact as to be flattened by mutual compression. Deglutition has 
now become not only difficult but painful, and in extreme cases well- 
nigh impossible. Drinks or fluid food may regurgitate through the 
nose. Coughing and strangling efforts attend the ingestion of food. 
The patient finds no rest in a recumbent posture. He sits up in bed 
or out of bed, nursing his head in his hands, or walks about the floor, 
a picture of suffering and distress. By this time the tonsils have 
assumed such magnitude as to be manifest on the outside of the 
neck, visibly or palpably. Any pressure upon them elicits or aggra- 
vates pain. 

Quinsy is naturally a suppurative disease. It was known for- 
merly as angina phlegmonosa. Sendtner found in a case the Strep- 






THE TYPHUS FEVERS. 259 

tococcus pyogenes, which could not be distinguished from that of 
common pus. It becomes, therefore, a necessity to recognize the 
presence of pus and evacuate it as soon as possible. The protruding 
point of suppuration may at times be seen as a grayish-white dis- 
coloration of the surface, more often felt in posterior and inferior 
portions of the tonsillar mass. If the finger be passed over the 
surface of the tonsil and swept around its circumference, while pres- 
sure from the outside pushes it into the throat, the point of tender- 
ness may be elicited, or, indeed, fluctuation felt. Masses of this 
magnitude block the Eustachian tube to produce more or less deaf- 
ness, and occlude the nares to interrupt respiration and alter the 
voice, stop the phaiynx to cause more or less profound dysphagia. 
There is also the possibility that rupture of the abscess in the tonsil 
may inundate the larynx. Fatal cases of this occurrence at night 
have been reported. In the natural course of events the abscess 
ruptures itself, to the indescribable relief of the patient. Quite fre- 
quently the disease stops short of suppuration, to undergo favorable 
resolution. The physician evacuates the pus, so soon as discovered, 
by a simple plunge of the bistoury, taking care to keep the knife 
parallel with the sides of the throat, or, if lie finds it necessary to 
make a longer incision, to cut from without inward, that he may 
avoid the carotid artery. Outside pressure will help to fix the tonsil 
in the desired position to secure proper penetration by the knife. 

The prognosis is not grave, notwithstanding the apparent sever- 
ity of the disease. Patients recover entirely, sometimes, however, 
with hypertrophied tonsils, which, in fact, most of these patients 
will have had before the attack. There are no means by which 
quinsy may be cut short, and still less prevented. 

Treatment consists in the application of moist heat — hot-water 
bandages, soft, hot poultices, hot-water gargles, inhalations of 
steam, whose efficacy may be increased by the addition of carbonate 
of soda — and especially in the speedy recognition and early evacua- 
tion of the abscess. Scarification and incision are not only useless 
but dangerous before suppuration. Sometimes the presence of pus 
may be recognized by means of a subcutaneous syringe — a safe and 
innocent procedure. Evacuation of the abscess ends the case. The 
salicylates, especially salipyrin, with Dover's powder, control any 
fever, light sepsis, or pain. 

THE TYPHUS FEVERS. 

Hippocrates used the term typhus (tvcpos, smoke) to describe a 
benumbed condition of the sensorium, as if produced by a cloud 
about the brain ; and the term was used for ages to indicate this in- 
tellectual obscurity, without reference to the name or character of 



260 THE TYPHUS FEVERS. 

the disease in which it occurred. So, meaning nothing more definite, 
it fell into complete disuse until the time of Sauvages (1760), who 
revived it with special application to particular forms, which we 
now recognize more distinctly as three varieties of typhus fever — 
first, the oldest, typhus fever ; second, a form separated in the 
fourth decade of the present century, typhoid — i.e., like typhus 
fever ; and the third, isolated distinctly by Obermeier in 1873 as 
typhus recurrens, or relapsing fever. All these forms were for- 
merly inextricably confounded, and the graver varieties were 
studied under the common terms of spotted fever, fleck- typhus, hos- 
pital, ship, and jail fever, hunger typhus, etc., as indicating a dis- 
ease produced by crowd-poisoning and following upon the heels of 
famine and want. Starvation, crowd-poisoning, filth, bad hygiene, 
these were the factors supposed to produce typhus fever spontane- 
ously — factors now recognized as important elements in the spread, 
but not in the development, of the disease. 

True Typhus, Typhus Exanthematicus. — Typhus fever 
prevails still in countries which represent the presanatory period of 
'civilization, raging with great virulence in Ireland and Russia, and 
occurring, only in much more modified form, at longer intervals, in 
seaport towns of our own country. Congregations of men in armies 
and upon pilgrimages have often since disseminated typhus fever. 
It causes, in fact, or has caused, more death in military life than all 
the battles and perhaps all other diseases put together. Typhus 
fever was one of the plagues of old times. 

History. —Typhus fever made its first appearance in our country 
in 1812 in New England, at which time it spread over the New Eng- 
land States, to thereupon disappear, and reappear only in 1836, on 
which occasion it visited Philadelphia in great virulence. Here, for- 
tunately, it fell under the observation of Gerhard, who drew the 
first distinctive lines between typhus and typhoid fever. As these 
points were subsequently presented to the profession, more especially 
by Jenner, of London, they soon obtained general recognition. A 
few cases have been imported since from time to time, last in 1892 
with one hundred and eighty-five cases, fifteen deaths. The disease 
lias not spread beyond our seaport towns. 

Etiology. — Typhus fever is pre-eminently a contagious disease, 
its infectious matter radiating from every surface and secretion. 
Susceptibility is almost, if not quite, universal, as the disease is ex- 
quisitely diffusible. The child of seven days, the old man of sev- 
enty years, are alike attacked. The poison may also be conveyed by 
third persons and by things. Physicians and nurses in direct con- 
tact with patients in hospitals fall frequent victims to this disease. 
The exact cause of the infection has not as yet been isolated. 



THE TYPHUS FEVERS. 261 

Opportunity for study in centres where the etiology of the disease 
is most diligently investigated has not occurred in recent times. 
Lewaschew, of Kasan, finds a peculiar spirillum, endowed with active 
motion, in the blood of the spleen, less constantly in blood from the 
finger, which he was able to cultivate apart ; and Cheeseman found 
in the blood of six patients a short, thick bacillus which he could cul- 
tivate upon agar and ox-blood serum, and which showed pathogenic 
properties, but not typhus fever, in rabbits, guinea-pigs, and mice. 
Typhus fever in its nature closely resembles a bad case of measles, 
in that the disease is so contagious, the liability is universal, in that 
the eruptions are much alike, and in that haemorrhage may occur in 
either. 

Symptoms. — The disease begins with a chill, or series of shiver- 
ing fits, attended by rise of temperature to 103° to 104° or 105° in 
the course of twelve to twenty-four hours. The onset of the disease 
is sudden, often in the midst of perfect health. Exceptional cases 
show prodromata for two or three days in the way of malaise, de- 
pression, headache, pains in the loins and limbs. There is from the 
start profound prostration, and, with the very inception of the dis- 
ease, overshadowing symptoms of mental dulness, drowsiness, 
sopor, deepening into stupor which readily passes over into coma. 
This is the cloud about the brain. In the first few days of the dis- 
ease, and throughout the whole course of the malady, however light 
the case, the symptoms on the part of the nervous system are ob- 
trusively distinct. 

By the third day the eruption appears upon the body, over the 
chest, to extend thence over the entire body, but to spare always, or 
nearly always, the face. The eruption shows itself in the form of 
maculae, crimson red, which soon become darker, and often co- 
alesce, to give the body a spotted appearance, from which it derives 
a popular name. So the body is more or less equally studded with 
points of intense hyperaemia, maculae, which may, as stated, co- 
alesce and form larger surface ecchymoses or vibices, especially in 
debilitated cases or bad surroundings. A peculiarity in the eruption 
of typhus fever is the fact that by the third or fourth day these 
maculae aggregate themselves into points of pinhead size filled with 
black blood — the so-called petech ice. Another very distinct pecu- 
liarity is the fact that the temperature does not fall with a full 
appearance of the eruption. In most of the eruptive diseases the 
temperature at its height represents the period of efflorescence, after 
which all the symptoms, as a rule, decline and disappear. But in 
typhus fever the appearance of the eruption has no effect upon the 
temperature, which remains, with diurnal variations and accidental 
complications, much at the level at which it began, up to the twelfth 



262 



THE TYPHUS FEVERS. 



to the fifteenth day, whereupon it falls more or less suddenly, to 
reach the normal grade within twenty-four hours, to constitute the 
so-called decline by crisis. Figs. 141-145, from Moore on Fevers, 
show the temperature in typhus fever. The crises of the ancient 
writers, marked by profuse sweat and diuresis, were based, for the 
most part, upon observations of cases of typhus fever and pneu- 
monia. The spleen is enlarged, as a rule, but not to the degree or 
with the uniformity that marks cases of typhoid fever. 

All this time the symptoms on the part of the nervous system 
continue or increase. The patient is at first preoccupied, abstracted, 






■°1 



lot,' 



a 



U 



t 



sf 



ii 



§ 



! 



B 



Fig. 141.— Temperature chart in adynamic petechial typhus fever. 



pays little or no attention to his surroundings, lies in a state of sopor 
which lapses into stupor; responds at first to sharp address rationally, 
later irrelevantly, and later still not at all ; lies in muttering deliri- 
um, slips down in bed like a leaden image, and may be pushed or 
pinched without a sign of feeling. 

Parenchymatous change affects the muscles; the voluntary mus- 
cles, and more especially . the heart muscle, suffer degeneration. 
This parenchymatous change is not the effect of the fever. Neither 
the delirium nor the degeneration is caused by the fever. They are 
both, with the fever, effects of a common cause. They do, as a rule, 
correspond. But cases of low fever may show great delirium. The 
converse is also true. Throughout the whole course of the disease 



THE TYPHUS FEVERS. 



263 



Da 



'3 



lOb 



/OS 






5 



I 



% 



'©*■ 



II 



t 



m 



/o3 



I 



/o2 • 



5 



9'9 



K 



95- 



Fig. 142.— Temperature chart in ordinary typhus. 



7 



IOL' 



i 



11111 



1 



5J 



*? 



?* 



Fig. 143.— Temperature chart in typhus fever. Resolution by continuous lysis. 



264 



THE TYPHUS FEVERS, 



*%* 



I OLf* 
J03<> 

}oZ° 
/ai v 

/Of' 

?r 



1 



m 



v 



A 



& 



Fig 144.— Temperature chart in typhus fever. Resolution by crisis. 



Disease 



JOfy"- 



fr- 
it- 

9 ? " 



Fig. 145.- 



n 



1 



i 



1 



YH 



S: 



a 



:s 



-Temperature chart in typhus fever. Resolution by crisis. 



THE TYPHUS FEVERS. 265 

there is great disturbance and distress on the part of the digestive 
system: the tongue is heavily coated, fuliginous; sordes accumu- 
lates about the teeth; later the tongue becomes dry, is fissured, and 
bleeds. By this time it may be no longer protruded from the mouth, 
or, if protruded under great effort, remains, and is not withdrawn un- 
til after repeated request. 

There is from the start anorexia, nausea, frequently vomiting, 
which is at times excessively defiant of control. As in all the grave 
acute affections where the intestinal wall is itself not affected, the 
bowels remain constipated throughout. 

The diagnosis is based first upon the existence of the disease in 
the land. In our country there is a history of direct importation and 
transportation to the individual case. Ireland, Russia, some parts of 
India, are the homes and haunts of typhus fever, and cases, to reach 
us, must follow the lines of travel. The disease begins suddenly, 
often without prodromata, and violently. The eruption appears 
on the third day as maculae over the body, to become after three 
days petechial. * The eruption spares the face. The appearance 
of the eruption is not attended with any fall of temperature. The 
symptoms on the part of the nervous system show themselves from 
the start, and prevail and predominate throughout the whole course 
of the disease. Abdominal symptoms are wanting. The fever 
falls on the twelfth to the fifteenth day, and the disease terminates 
by crisis. 

Typhus is distinguished from typhoid fever by the sudden onset 
of typhus, or more protracted, insidious onset of typhoid. One 
attack of typhus secures but temporary exemption; one attack of 
typhoid confers immunity, as a rule, for the rest of life. The ner- 
vous symptoms show themselves in the incubative and prodromatous 
stage of typhoid, and but for a few days, if at all, before the out- 
break of typhus. Typhoid fever is frequently announced by nose 
bleed, absent in typhus. It is the ' upper respiratory tract which is 
attacked in typhus, along with the rest of it. In typhoid fever the 
bronchial tubes only are involved. Thus there is bronchitis in both 
diseases, but there is also coryza in typhus fever, with irritation in the 
nose, sneezing, which almost never occurs in typhoid. Constipation 
is the rule throughout the whole course of typhus fever. There may 
be constipation during the first week in typhoid, but, as a rule, there 
is more or less diarrhoea from the start. The spleen is more distinct- 
ly and more constantly enlarged in typhoid fever. The eruption ap- 
pears on the third day of typhus fever, more or less universally over 
the body. The eruption appears in typhoid fever on the chest about 
the seventh to the tenth day. It is much more scanty and much more 
distinctly isolated. Typhus fever often shows herpes on the face, 






266 RECURRENT FEVER. 



typhoid almost never. The duration of typhus fever is two, typhoid 
fever four weeks. 

Typhus fever is distinguished from measles, which it more closely 
simulates, by the fact that typhus attacks all ages, measles chiefly 
children. This fact is not due to the greater liability to measles, but 
to the fact that measles prevails always, and typhus only at inter- 
vals. Measles is preceded for three days by coryza; typhus shows 
coryza at the onset of the disease proper. Measles has a period of 
invasion of three or four days; typhus begins at once. The eruption 
in typhus fever appears on the third day on the body; of measles 
on the fourth day on the face. The eruption of measles occurs in 
patches or individual spots in spreading over the body, including the 
face where it begins ; the eruption of typhus is more universally 
distributed over the body, sparing the face. The eruption of measles 
remains . macular and disappears by branny desquamation ; the 
eruption of typhus becomes petechial and disappears by absorption 
without desquamation. 

The prognosis of typhus fever is always grave, yet its gravity 
has been reduced in our period by sanitation, relief from crowd and 
sewage poison, to twenty per cent. The therapy of the disease is 
wholly symptomatic and will .be discussed with that of typhoid 
fever. 

REFURRENT FEVER. 

Recurrent (relapsing) fever has been distinctly recognized in the 
history of the graver infections since the beginning of the eighteenth 
century, though its differentiation from other forms of typhus, more 
especially true typhus, is an acquisition, as stated, of very recent 
times. Recurrent fever has its home in Ireland and the east of 
Europe, whence it has been carried, often in epidemic proportions, to 
various parts of the earth. 

Etiology. — Recurrent fever arises only from itself. It is rapidly 
disseminated in unsanitary conditions. It has in this regard the 
same history as true typhus. The disease is declared to be con- 
tagious. There is no individual immunity. Immunity is not con- 
ferred even by a single attack, which seems rather to predispose to 
other attacks. Recurrent fever is now known to be caused distinctly 
by the invasion of a special micro-organism, the spirillum or spiro- 
chetes of Obermeier (1873). 

Bacteriology. — These spirilla, interesting as the first micro-or- 
ganism actually seen in the blood or body of man, exist in the blood 
only during the period of fever. They disappear entirely from the 
blood of the dead body. They are long (16 to 40 /*), spiral threads, 
curled like a corkscrew, and endowed with active motion, both spiral 



RECURRENT FEVER. 



267 



and undulatory. Though attempts at outside cultivation have not 
yet been successful, the introduction of blood containing the parasite 
-conveys the disease to other animals (apes) and to man. 

Pathology. — The changes in the body do not differ much from 
those of typhus. There is rather more predominating evidence of 
parenchymatous degeneration of the liver, and at times such disten- 
tion of the spleen as to lead to rupture of its capsule. The disease is 
more fatal in the ape after exsection of the spleen. Thus antimycotic 
action is ascribed to the spleen. While the mesenteric glands are 
enlarged, the plaques of Peyer and solitary follicles remain un- 
affected. Haemorrhages, petechia?, etc., occur occasionally, and 
icterus so frequently as to sustain the view of "bilious typhoid." 
This is one of the diseases included under the old " bilious typhus." 

The period of incubation is five 
io seven days. The disease begins 
generally with a sharp chill, rap- 
idly rising fever, severe pains in 
the joints, with rapid prostra- 
tion and gastric distress. Icte- 
rus occurs as early as the fourth 
da}-. Enlargement of the spleen 
may be soon detected. Mental 
distress and delirium may show 
themselves at once. 

What distinguishes the disease 
in any doubtful case is the dis- 
appearance of all these symptoms, 
however severe, so soon as they 
reach their height. At the end of the first week, when the patient 
shows such prostration and grave symptoms as to excite intense 
solicitude, the symptoms all speedily subside, the temperature reaches 
its natural limits sometimes in the course of a few hours, and the 
patient seems to have perfectly recovered. Somewhere between the 
fourth and the fourteenth day the same symptoms show themselves 
■aneiv. They may be equally severe in their recurrence, but are, as 
a rule, much shorter in their duration, lasting from two to four days, 
when the temperature again falls and the symptoms subside as 
before. In most cases this is the end of the disease. In exceptional 
cases the patient may experience a third or fourth relapse. 

Diagnosis. — Relapsing distinguishes itself from typhoid fever 
by the suddenness of its onset, or violence of the pains in the bones, 
muscles, and joints, and the secondary and subordinate character 
of the brain symptoms. Hebetude and headache are not so marked 
in the course of relapsing fever. Enlargement of the spleen occurs 




pirilla of relapsing fever in the 



268 



TYPHOID FEVER. 



early and is equally marked, but symptoms on the part of the liver 
assume much greater prominence than in typhoid fever. There is- 
usually more or less icterus. Herpes, which is almost never seen in 
typhoid, is not infrequent in relapsing fever. The diagnosis rests 
further upon the apparent termination of the disease at the end of the 
first week, and its recurrence once or twice. It really rests upon the 
discovery of the spirillum in the blood. Examination is made in the 
same way as for malaria. 

The treatment is wholly symptomatic. It differs in no way from 
that of typhoid fever. 



II iiill iiyiiiiiliiiiiSiSii 

iiiiliiilK III! IIHigl SHBlinB 

iiiiiiil 




ssss::ssii 

— iir — 

St 



sssssss 

KB 



lilHIIIiii 

Iiiiiiil 
iliiliiilii mm 



111111 HUH 



Fig 147.— Temperature chart, relapsing fever (Seguin). 



TYPHOID FEVER. 

Typhoid fever (rvcpos, smoke; eido?, like — i.e., like typhus fever) ;■ 
typhus abdominalis, ileo-typhus, enteric fever; German, Nerven- 
fieber; Iceland, lands far sot, sickness of the country. — An acute in- 
fection, caused by a special bacillus, characterized by slow, insidious- 
onset, hebetude, headache, typical fever, roseola, enlargement of the 
spleen and mesenteric glands, swelling and sloughing of intestinal 
glands (Peyer's patches), diarrhoea, meteorism, liability to peritoni- 
tis and intestinal haemorrhage, and termination at about the twenty- 
first day. 

History. — Typhoid fever is a disease of comparatively modern 
recognition. Although the term typhoide was proposed by Louis in 
1829, the disease was distinctly separated from typhus in the fourth 
decade, and from recurrent fever in the seventh decade of the present 



TYPHOID FEVER. 269 

century. The first attempt at separation of typhoid from typhus 
fever arose from the recognition of anatomical lesions in typhoid as 
•distinct from typhus fever, first made by Prout in 1804; but the dis- 
ease, then and for a long time after regarded as a milder variety 
of typhus, was clinically distinguished only in 1840 to 1850 by the 
observations of Gerhard and Pennock, of Philadelphia; Skat-tuck, of 
Boston; and Barlow and Jenner, of London. Tke Bacillus typkosus 
was discovered by Ebertk and verified by Kock in 1880. Very fine 
illustrations of tke lesions of tke intestines are to be found in tke 
" Medical and Surgical History of tke War of tke Rebellion, " 
1888, by Ckarles Smart, Surgeon U. S. A. 

Etiology. — Typkoid fever is tke most frequent of all tke acute, 
grave, infectious diseases. It attacks all ages, but spares tke ex- 
tremes of life. One-kalf of all cases occur between the ages of fifteen 
and twenty-five; one-fourth under fifteen; one-tenth between twenty- 
five and thirty. Liability begins to cease at thirty-five, and is almost 
null at fifty. Yet cases do occur in the most extreme age, as verified 
by autopsy. So, too, cases have been recognized in early childhood. 
One should be slow in childhood, and extremely loath in advanced 
age, to accept the diagnosis of typhoid fever. Most of the cases of so- 
called typhoid fever in inf ancy and age are typhoid states of other dis- 
eases — pneumonia, tuberculosis (marasmus), etc. The disease may 
occur at any time of the year, but prevails especially during the fall 
and winter. It coincides with stages of low water. Typhoid fever 
is now known to arise only from itself, and to be chiefly conveyed by 
drinking water (including diluted milk) contaminated with the faeces 
of typhoid-fever patients. 

Bacteriology. — The typhoid bacillus — Koch-Eberth bacillus — is 
a short, thick rod with rounded ends, three times as long as broad, 
rendered easily visible by saturated alcoholic solutions of metkylene 
blue. Vacuoles in tke ends of tke vessels are 
taken for spores. Tke bacilli are recognized en 
masse in tke intestinal wall; in tke plaques and 
follicles; in tke mesenteric glands, spleen, ''-*v'' "!«»7\7d 

■whence they have been withdrawn in life; *^^/>^«W 

much less abundantly in the liver, lungs, brain ^'^T7<S?< ^ 

(meninges), and kidneys (urine). Tkey kave fig.us.— Typhoid bacillus. 
been recovered occasionally also in tke faeces, ai ' ecutme ' 
and kave been absolutely recognized in tke spots of roseola which 
belong to tke disease. Tkey may pass tke placenta, presumptively 
only after some lesion of its structure, for tkey kave been found in 
tke blood of tke foetus. Tkis bacillus is endowed witb motion, grows 
rapidly upon various culture soils, especially upon the cut surface of 
a sterilized potato, where it forms yellowish, circumscribed colonies 




270 



TYPHOID FEVER. 



so characteristic as to distinguish it in doubtful cases. The typhoid 
bacillus continues to grow in the presence of acid of high degree. 
It will show all its characteristics in an acidified gelatin highly 




Fig. 149 

intestine. 



-Typhoid bacilli in the wall ot* the 



Fig. 150.— Typhoid bacilli from section of 
spleen (Fliigge). 



colored with methylene blue, which simulating bacilli will not 
(UfTelmann). - Other bacilli of the colon decompose glucose with 
the evolution of gas; the typhoid bacilli do not (Theobald Smith). 
(Vide Frontispiece, Figs. 9 and 15.) 

It was difficult to fulfil the three postulates required to establish 
the pathogenetic nature of the typhoid bacillus, because animals 

seem naturally immune to the 
disease, and because an active 
gastric juice destroys the bacillus. 
But when the acidity of the gas- 
tric juice is neutralized with soda, 
and the peristaltic motion of the 
intestine is checked by the use 
of opium, or if the culture soil 
containing the bacillus be intro- 
duced directly into the duode- 
num, certain characteristic symp- 
toms supervene, as alteration of 
Peyer's plaques and swelling of 
the mesenteric glands, etc. 

Sirotinin, Beumer, Peiper, 

and others made the important 

discovery that the culture soil, 

sterilized by heat enough to destroy the typhoid bacillus, produced 

when injected, the same symptoms; so that the poison of typhoid 




Fig. 152.— Typhoid bacilli in mucous mem- 
brane of small intestine (child): a, epithe- 
lium of crypts, b, small round cells like adenoid 
bodies; c, typhoid bacilli in colonies. 



TYPHOID FEVER. 



271 



fever is known to be a chemical agent, the so-called typhotoxine, 
sin^ce extracted (Brieger), which produces the fever, the nervous 
symptoms, and other conditions which distinguish the disease. The 
micro-organism finds its way from the discharges into the drinking- 
water, and is thence conveyed into the body of man to produce the 
disease. The bacillus of typhoid fever does not live very long in 
drinking water, perishing, as a rule, in from seven to fourteen 
days, so that the spread of typhoid fever to endemic or epidemic 
proportions implies a continued contamination of the drinking 
water. Under favorable conditions, as in dung heaps, sewage, etc., 
the bacillus may live as long as three months, the outside limit of life 
(Karlinski). Boiling water thoroughly destroys this bacillus and 
purifies it for drinking purposes. 

Symptoms. — The period of incubation of typhoid fever varies 
from two to three weeks, during which time the individual affected 




Fig. 152.— Typical temperature curve in severe typhoid fever (Eichhorst). 



may present few or no alterations from health. In most cases, how- 
ever, there is, during this whole period, more or less malaise, languor,, 
debility, headache, neuralgic pain, anorexia, and constipation or 
diarrhoea. The disease sets in with a chill, or series of shivering fits, 
and, as a rule, a p)rostration, to such a degree as to early put the 
strongest men to bed. In about one-fifth of the cases the disease is. 
announced by an epistaxis, and, in the absence of free hemorrhage, 
scales or stains of blood about the nose and the fingers, which have 
been used to relieve irritation, are suggestive signs to the observant 
practitioner. The typhoid state early assumes prominence. As 
stated, at times during the whole period of incubation — in nearly all 
cases with the earliest inception of the disease — there is droivsiness, 
dulness, languor, headache, inability of concentration, apathy, and 
depression of spirits. This condition exists from the start in greater- 



272 TYPHOID FEVER. 

or less severity, and prevails throughout the disease, to deepen often 
later in its course into states of muttering delirium, mania, and 
coma. 

The factors which assume prominence at once are those which 
have given the name to the disease — namely, the typhoid state and 
the fever. The fever of typhoid fever is peculiar. The disease dis- 
tinguishes itself in all its symptoms by insidious development, and 
the slow onset is manifest also in the fever. The fever rises, as a 
rule, a degree a day for seven days. It is one degree higher in the 
evening than in the morning of the same day, and one degree higher 
in the morning than the morning of the previous day, so that the 
typhoid-fever curve is often said to show a stepladder ascent. The 
height which the fever attains by the end of the first week is some- 
thing of an index of the gravity of the case. By the end of the first 
week the fever becomes more or less continuous. It shows the 
diurnal variations, but, barring complications, it holds itself on an 
elevated line, four to six degrees, above the normal for two weeks. 
Then, by the end of the twenty-first day, the fever falls. It may 
reach the level of the previous night for two or three successive 
evenings, but it falls lower every morning, until in the course of 
another week, by the twenty-eighth day, it reaches finally the normal 
grade. Thus typhoid fever is often divided into weeks: first a week 
of ascent, second the two weeks of continuous elevation, third the 
week of marked remission up to the conclusion of the disease. These 
weeks correspond quite closely to the anatomical lesions in the intes- 
tinal canal. During the first week the glands and follicles are in 
a state of hyperemia; during the second week there is associated 
tumefaction; during the third week the glands slough; during the 
fourth week they cicatrize. 

Typhoid fever shows early a symptom of importance in an 
enlargement of the spleen. The spleen begins to swell in the first 
days of the disease, and by the end of the first week may be recog- 
nized as substituting its dulness for the tympanitic resonance of the 
fundus of the stomach, as it begins to encroach upon the abdominal 
cavity. 

Typhoid fever is often distinguished as ileo-typhus because of the 
localization of its lesions about the lower region of the ileum. The 
bacillus passes the stomach, upon which it can produce no effect. It 
is hurried on by the more rapid peristalsis of the duodenum, jeju- 
num, and upper to the lower part of the ileum, where obstacle is 
offered to rapid escape of the fluid contents of the stomach by the 
ileo-ca3cal valve. Here, at this comparatively stagnant reservoir, 
the bacillus makes its attack upon, or is incorporated in, the intestinal 
wall, to be carried thence through the blood and lymph vessels to 



TYPHOID FEVER. 273 

the mesenteric glands and spleen. Symptoms on the part of the 
intestinal canal present themselves therefore early, assuming promi- 
nence later in the course of the disease. 

Some few exceptional cases are marked by constipation during 
the first week, but as a rule diarrhoea exists, often early, always 
later, sometimes profuse in the later period of the disease. The 
abdominal wall soon becomes distended. There is meteor ism. Per- 
cussion is tympanitic. There is tenderness to pressure. There is 
gurgling in the region of the right iliac fossa. 

The disease is called ileo-typhus, typhus abdominalis, as distinct 
from typhus exanthematicus, fleck-typhus, spotted typhus or fever, 
because of the prominence of the eruption in typhus fever. But 
typhoid fever is not without an eruption. Typhoid fever has a quite 
characteristic eruption, which appears upon the surface of the chest 
or abdomen, about the region of the diaphragm, in the form of small 
red spots, " rose-colored, lenticular spots" (Louis), which appear to 
the number of five to fifteen distinctly macular, subsequently slightly 
elevated spots, like flea-bites, which disappear upon pressure, to re- 
appear with its relief. These rose-colored spots, scattered usually 
over the chest and abdomen, have at times a more profuse and wider 
distribution. They may appear first in the loins, and may be ob- 
served only on inspection of the back. They may extend over the 
chest, over the whole abdomen and upper part of the lower extremi- 
ties, and be even crowded over upon the neck to the number of 
several hundred. They may appear, disappear, and reappear in the 
further course of the disease. They are present in the majority of 
cases, and form, while not pathognomonic, certainly strong corrobo- 
rative evidence of the nature of the disease. Cases sometimes show 
no spots. Chomel speaks of an epidemic at Turenne where spots 
appeared in no case. They do appear in the great majority of cases, 
and at about the period of the disease mentioned, and are strong 
points in the recognition and diagnosis of typhoid fever. 

The discharges of typhoid fever are more or less distinctive. 
They consist at first of the natural contents of the intestinal canal. 
Later they become more fluid, assuming a distinct consistence and 
color. The old writers spoke of the "pea-soup, ochre-colored " dis- 
charges of typhoid fever. This character is sometimes markedly 
changed by the appearance of blood. Some blood appears in the 
discharges of nearly all cases of typhoid fever, but, as a rule, in 
minute quantity. Discharges are called bloody, only when the blood 
may be recognized with the naked eye. The discharges in typhoid 
fever are frequently stained with blood, or contain blood in quanti- 
ties, or consist wholly of blood. Individuals have succumbed to 
haemorrhage in this way. The rule is, that the discharges are 
18 



274 TYPHOID FEVER. 

bloody for a time, several days, that haemorrhages occur during this 
period, that the bleeding ceases probably with the block of the vessel, 
to recur with dissolution of the clot, or with the reopening of an 
ulcer, or from a new ulcer. 

All this time the typhoid state deepens. The patient complains- 
at first only of headache, of drowsiness, or his sleep deepens into 
states of stupor. After a while the condition continues more perma- 
nently ; the patient is in a more or less constant state of vacancy or 
stupor. If spoken to or sharply addressed he may answer rationally 
at first, or later make some unintelligible or irrelevant response. If 
asked to protrude the tongue he may fail at first to comprehend, but 
if the request be made manifest by pressure of the finger upon 
the chin, the tongue is with effort protruded, as a heavily coated, 
fuliginous, tremulous mass, which remains protruded until the pa- 
tient is admonished by injunction or touch to withdraw it. The pa- 
tient falls into a state of mild delirium. He seems constantly and 
incessantly occupied. The mind is busy, in the strict sense of the 
term — so busy as to prevent sleep. There is low, muttering delirium, 
a state of stupor with vigilance — a condition which is well described 
under the term coma-vigil. The body becomes more and more 
an inert mass. There is no effort on ^he part of the patient. The 
most imperative wants of the body pass unrecognized. The dis- 
charges are voided unconsciously and involuntarily. The patient 
slips down in bed, and must be continually lifted toward the head 
of the bed. Flies crawl unnoticed over the face. There is no per- 
ception of heat or cold. All the while the mind seems intently pre- 
occupied. Soon there is subsultus tendinum. The patient picks at 
the bedclothes. The face is dusky. The prostration is profound. 
Heart failure or thrombus may close the scene. 

Fortunately such cases are rare in our day. The old pictures of 
cloud and collapse are seen only in neglected cases, especially in 
cases which remain as lorig as possible out of bed, whereby the 
strength which should be saved for resistance is wasted away, 
whereby also tendency to haemorrhage or peritonitis is increased. 

Hcemorrhage and perforation are the accidents most to be 
feared. Slight haemorrhage may show at any time in the course of 
the disease, but such an amount of blood as to be visible to the' 
naked eye, or to constitute most or all of the discharge, occurs, as a 
rule, in the third and fourth weeks of the disease, and is due to the 
erosion of a blood vessel or the reopening of a cicatrization. A 
haemorrhage is recognized at once by the presence of blood, or, if 
the blood be concealed — that is, retained in the intestinal canal — by 
the collapse into which the patient sinks ; by the fall of the tempera- 
ture suddenly from 104° or 105° to 100°, to the normal, or even to 



TYPHOID FEVEE. 275 

subnormal grades. There is, after such copious haemorrhage, an 
illusory improvement in the mental state. The patient awakens 
from coma, or appears more rational and bright. The temperature, 
however, speedily reaches its former, or often higher, level, and the 
strength and the mental state are reduced more than before. While 
it is a rule that haemorrhage occurs more especially in bad cases, 
there are many exceptions. Fatal haemorrhage has taken place in 
cases so light as not to have confined the patient to bed, and patients 
have even bled to death from a single ulcer. But the haemorrhage 
is by no means necessarily fatal. The usual history of a haemor- 
rhage is its occurrence in quantity, disappearance for several days, 
and recurrence perhaps on several subsequent occasions. The stools 
of a single day, or of twenty -four hours, are bloody or all blood. On 
the following day the condition is more normal. On a subsequent 
day the haemorrhage returns. 

Of all the accidents that befall a patient with typhoid fever none 
is so grave as perforation. This accident, as a rule, occurs in close 
proximity to the ileo-caecal valve, where the ulcers are most abun- 
dant and deep. The condition is announced, for the most part, by 
sudden, profound collapse. The face is pinched, the eyes sunken ; 
the surface is cold, often clammy ; the pulse is feeble or almost im- 
perceptible, thready. The patient often lies in bed with the knees 
flexed to relax the abdominal wall. The abdomen itself is distended, 
tympanitic. The dulness of the liver and spleen is substituted by 
tympanitic resonance. A mistake may here readily arise from a dis- 
tended colon, which may itself substitute the hepatic arid splenic 
dulness. In perforation the temperature usually falls suddenly, and 
often to a subnormal degree. The patient may become rational. 
There is an illusory appearance of resolution of the disease. These 
hopes are, however, speedily abandoned, as the collapse continues, 
to end in death in twelve to twenty T four hours. 

Peritonitis by no means of necessity implies a perforation. An 
ulcer may affect the peritoneum without perforating it. In this 
case, for the most part, the peritonitis is circumscribed, and points 
or surfaces of tenderness may be elicited by gentle pressure over the 
abdominal wall. A circumscribed peritonitis may become diffuse 
when no perforation exists. 

Typhoid fever presents two sets of complications — one which 
applies to the disease proper, and one common to other infections. 
The lesions peculiar to the disease include the swelling and ulcer- 
ation of the glands in the intestine, and affection of the spleen and 
other lymphatics. The second set of lesions are the parenchy- 
matous degenerations, that have been usually ascribed to the 
height and duration of the fever, but are considered in our day to be 



276 TYPHOID FEVER. 

due to the poisoning of the blood. These states affect chiefly the 
muscles, which undergo granular, fatty, and waxy degenerations, to 
such a degree at times as to lead to paralysis, ruptures, and failures. 
Thus the heart may become feeble or cease to beat, the diaphragm 
enfeebled or paralyzed, and voluntary muscles may rupture. The 
author has seen rupture of the rectus abdominis. 

Typhoid fever is a treacherous disease, and no disease is attended 
with so many pitfalls in the way of complications and sequelae. 
Haemorrhage, perforation, peritonitis, may occur in any case unex- 
pectedly. Among the more uncommon sequelce may be mentioned 
laryngitis, which may assume a diphtheritic character and neces- 
sitate tracheotomy. Parotitis on one or both sides sometimes pro- 
ceeds to suppuration, probably as the result of a mixed infection. 
About once in a hundred cases there occurs thrombosis of the fem- 
oral vein — phlegmasia alba dolens. Although albuminuria occurs 
in perhaps every case at the height of the fever, typhoid fever is 
very rarely followed by Bright's disease. Pyaemia occurs as a rare 
exception. Bronchitis belongs to the disease, and lobular pneumonia 
may result from it. Pleurisy, pericarditis, endocarditis, are among 
the rarer complications. So certain cases of valve disease of the 
heart owe their origin to typhoid fever. Bed sores are common, and 
show themselves in aggravated form in protracted cases, defiant of 
all relief at times until the period of natural resolution, when they 
are wont to take on a new aspect and heal up. 

Typhoid fever shows itself in various forms. There is : 1. The 
abortive form, in which the disease, while commencing violently 
and showing all its signs, terminates at the end of the second week. 
These cases are not so uncommonly rare. Protracted forms, where 
the disease extends into the fifth or sixth week and beyond, are by 
no means rare, and must not be confounded with relapses, which 
imply a previous return to the normal temperature. 2. The ful- 
minant form, where life is taken in the course of a few days, as 
under the action of a virulent poison. 3. The disease differs some- 
what in children, in that the eruption is by no means so abundant or 
distinct. The onset of the disease is more abrupt, the pulse and 
heart's action are not so much enfeebled. 4. In the aged the fever is 
not so high, diarrhoea is not so severe or persistent, eruption is not 
so abundant or distinct. There is more apt to be earlier and longer- 
continued muttering delirium. Prostration comes on quickly and 
continues after the subsidence of the fever, while other nervous 
symptoms of alow character — tremors, subsultus tendinum, etc. — are 
more constant. 

Such cases are only to be considered relapses wherein, as 
stated, the temperature reaches the normal grade. Testimony dif- 



TYPHOID FEVER. 



277 



fers as to the frequency of this accident, and confusion has arisen 
in regarding or not as relapses those recrudescences of fever which 
ma}* be provoked by errors of diet, exciting causes, emotional anx- 
iety, premature physical 
effort, etc. In these cases 
the fever subsides in the. 
course of a few days, 
whereas in the true relapse 
the whole scene is repeated 
in at least a great part of 
its role. Relapses usually 
begin more abruptly, the 
temperature sooner reaches 
its maximum grade. The 
rose-colored eruption ap- 
pears earlier, even on the 
second or third day ; the 
disease subsides more rap- 
idly. Thus the duration 
of the case may extend 
to include two or even 
three distinct attacks of 
the disease. An abortive 
case may be followed by 
distinct attack, or the case 
may consist of a distinct 
attack followed by two 
abortive relapses. 

Typhoid fever, as a 
rule, lasts twenty-one days 
or thereabout — that is, the 
fever begins to break on 
the twenty-first day, to 
terminate by the twenty- 
eighth day, so that the 
average duration of the 
disease may be regarded 
as about one month. Com- 
plications may vastly pro- 
long its duration. Death 

. , ~ Fig. 153o. 

may occur at any period, ot fever 

the disease, rarely before 

the end of the first week. 

after the disease has run its course, as the result of some sequel. 



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(Vide p. 278 ) 



Primary 



Death may occur, again, several weeks 



278 



TYPHOID FEVER. 



The diagnosis rests upon : 1. The typhoid state — i.e., the dul- 
ness, headache, insomnia, etc. 2. The fever with its gradual ascent 
and sustentation at a plane much above the normal for three weeks. 
3. The abdominal symptoms, the diarrhoea, the stools, meteorism, 




Fig. 1536.— Typhoid fever with relapse after twenty-four days 1 interval. Relapse (Moore). 

enlarged spleen. 4. The roseola. 5. The complications, especially 
the haemorrhage, heart failure, peritonitis. 6. The bacillus extracted 
from the spleen. 

Prognosis. — From what has been said regarding complications of 



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Fig. 154.— Typhoid fever with recrudescence. 



typhoid fever, it must be regarded always as a very grave disease. 
The prognosis must be guarded. In childhood the prognosis is by 
no means so grave. Accidents and complications are much less 



TYPHOID FEVER. 279 

frequent. Nearly all children recover. At puberty the disease begins 
to assume gravity, and the gravity increases with advancing years. 
We base the prognosis, 1, upon the degree of fever. Fiedler says 
that all cases die when the fever once touches a temperature of 107°; 
one-half die at 106°, one-fourth at 105°. Murchison reported a recov- 
ery after a temperature of 108°. Hutchinson states that the highest 
temperature reached in any of his cases was 106°. In this fatal case 
the temperature reached 105° five times. So single elevations of tem- 
perature to extreme degrees indicate gravity in this more than in 
any other febrile disease. Unusually protracted temperatures, though 
far less high, into the fourth week arid beyond, give great gravity. 

The prognosis is based, 2, upon the character of the complication. 
A new gravity is imparted to the case by haemorrhage. Cases in 
which haemorrhage is profuse or repeated furnish a mortality of 
thirty to forty per cent. Peritonitis is very grave. Perforation is 
not quite, but is almost, necessarily fatal. Rare cases are rescued 
by agglutinative inflammation. 3. The condition of the heart is a 
criterion of the danger. The pulse seldom rises above 100 to 120 
throughout the course of typhoid fever. The more frequent pulse 
betokens gravity. The strength of the heart's action, independent of 
its frequency, is an index of the gravity. 4. The time when a pa- 
tient is put to bed determines to a great degree the future of the case. 
Hospital cases which go to bed late have, notwithstanding care and 
skill, a greater mortality than cases in private practice which are put 
to bed at once. An early decubitus economizes force as well as pre- 
vents complication. 

Lastly, the outlook of the case is determined by its surroundings. 
The prognosis of typhoid fever depends largely upon the attention 
which it may receive. Under the improved methods of treatment of 
the present day the mortality of typhoid fever is reduced to seven to 
ten per cent. 

Prophylaxis. — Typhoid fever is a preventable disease. With our 
knowledge of the nature of its cause, it is necessary to secure pure 
drinking water to prevent typhoid fever. To avoid contamination of 
drinking water by human excrement rescues a community from the 
dangers of this disease. Where this condition cannot be complied 
with, thorough boiling of the water destroys the parasite which pro- 
duces it, and renders the water safe. So, also, perfect filtration 
through porcelain or asbestos prevents the passage of the germs. Un- 
fortunately the disease occurs, at times, where these precautions are 
taken, by neglect of the milk, which is often diluted with contaminated 
water. The disease may be contracted, where even this precaution is 
observed, by the ingestion of drinking water elsewhere than at home. 

Prophylaxis includes cleanliness about the sick-room, especially 



280 TYPHOID FEVER. 

with regard to the bed linen and the utensils employed in the treat- 
ment of the disease. Washerwomen, by careless handling of linens, 
often contract the disease by direct infection. 

The treatment of typhoid fever is wholly symptomatic. The 
hopes entertained regarding the jugulation, mitigation, or abbrevia- 
tion of the disease with specifics have proven groundless. The pre- 
parations of iodine, carbolic acid, calomel, hydronaphthol, etc. , have 
been recommended as antimycotic agents, but without evidence of 
real value. When it is remembered that typhoid fever is a disease 
of long incubation, that the poison is received into the body at least 
two weeks before the manifestation of symptoms, by which time micro- 
organisms have penetrated into the recesses of tissues out of the reach 
of remedies introduced into the intestinal canal, it may be understood 
why hopes of parasiticidal agents may not be entertained. More is to 
be expected of some protective proteid or antitoxine, and hope is en- 
tertained that available antitoxines may be extracted from the blood 
of patients who have just survived or recovered from the disease. 

As stated, the success of treatment is based largely upon the sur- 
roundings of the patient. After the diagnosis is established, treat- 
ment of an ordinary case, aside from complications, is more a matter 
of good nursing than of scientific skill. The temperature of the room 
should be maintained at 68°, as established hy a thermometer at the 
head of the bed. Ventilation must be secured from outside air. The 
bedroom should be faultless in its cleanliness, and, with the linen 
of the patient, should be changed, where it is possible, every day. 
An additional bed, sofa, or lounge, to which the patient can be trans- 
ferred absolutely without effort on his part, best secures this object. 

A typhoid-feyer patient must go to bed at once, and remain in 
bed, without rising under any pretext, throughout the whole period of 
the disease. Haemorrhage and perforation, the evils most dreaded 
in this disease, occur much more frequently in patients who change 
posture than in those who lie, recumbent and at rest. 

The diet must be fluid. Milk is the food par excellence when not 
especially contra-indicated, as by natural aversion, too much con- 
stipation, etc. Under such circumstances, or even when the milk 
is well borne, it may be substituted or supplemented by beef tea, 
chicken soup, mutton broth, oyster soup, and later, in beginning con- 
valescence, diluted eggs and thin custards. Fermented milk, sour 
milk, buttermilk, koumyss, may be taken when other preparations 
pall. Solid food is on no account to be administered to a typhoid- 
fever patient until the temperature shall have remained in convales- 
cence for three days at the normal grade. Fluids must be given to a 
typhoid-fever patient regularly. Cold water must be accessible, 
fresh, pure cold water, at all times; and in the states of pre-oecupation,, 



TYPHOID FEVER. 281 

delirium, coma, cold water must be not so much offered as adminis- 
tered at regular times. A grateful drink, in the absence of diarrhoea, 
is the prescription of Cheyne as improved by Graves : 

B Sodii carbonatis 3 i. 

Sued limonis - § i 3 vi. 

M. et adde, 

Tincturae aurantii recentis 3 i j • 

Syrupi aurantii 3 ss. 

Aquae ad § vi. 

M. S. A wineglassful every three or four hours. 

Graves says nothing is more agreeable to a fever patient than this 
mixture. The citrate of sodium thus formed "tends to keep up a 
soluble state of the bowels and forms a most grateful and refreshing 
beverage." The mouth should be washed out two or three times a 
day with solutions of borax. Vaseline, or, better, borated vaseline, 

B Acidiborici . ; gr. xv. 

Unguenti petrolati, 

Lanolini aa 3 ij . 

is to be introduced at the nostrils, not deeply inserted, to liquefy and 
disseminate itself through the nasal fossae and the pharynx. The 
face, neck, and chest should be sponged with fresh water or with 
Cologne water two or three times a day. 

The conditions which may call for special treatment are, first, the 
typhoid state and the fever. Some hebetude, headache, drowsiness 
belong to every case and call for no treatment. Headache in excess 
may be controlled by moderate doses, gr. x.-xv., of the bromide 
of sodium, largely diluted, every three or four hours. Light deliri- 
um may be met in the same way. Vigilant states may be combated 
by sulphonal, gr. x.-xv., in a bowl of warm milk or a cup of hot tea; 
trional, gr. xv. , or, in the earlier periods of the disease, by chloral, gr. 
v.-xv., in half an ounce of peppermint or orange-flower water. 
Nervous distress is best controlled by small gr. ij.-v. doses of pure 
chloral. When these hypnotics fail resort must be had to morphia, 
gr. -$— £, administered, where the tongue is dry or in the presence of 
nausea, preferably subcutaneously. Morphia may become in certain 
cases indispensable, but should be used only after failure of milder 
means, and always with judgment. In the rarer cases of maniacal 
excitement necessary supervision must be secured. 

Some fever belongs to the disease and may be allowed to run. 
Fever above 103° in the rectum becomes 'excessive. The dangers of 
typhoid fever are no longer attributed to the fever. The fever is 
looked upon, not as the cause, but as the effect of the poison of the 
disease, as a coeffect with other symptoms; and while it is true that 
the range of the fever is a gauge of the gravity of the disease, it is 



282 TYPHOID FEVER. 

not true that the control of the fever subdues the disease or controls 
the condition. The fact is that in our day treatment of the fever is 
more an address to the comfort than the safety of the patient. 

The best antipyretic is the cold bath. To be effective the patient 
must be lowered by sheets, held at the four corners, into a full-length 
cold bath, where he is to remain at first five, then ten, later fifteen 
minutes or more, when he is to be removed to bed with the same 
care, gently wiped off, covered with blankets, and allowed, if he 
may, to sleep. The bath is cold when the temperature is 68° F. It 
is sometimes advisable to commence with a warmer bath, 75° to 80°, 
even 90°, and gradually cool it down with lumps or masses of ice. 
The bath should be administered whenever the temperature reaches 
103° in the rectum, where alone reliable records can be read, every 
hour if necessary, precaution being taken to secure the advantage of 
the bath between midnight and morning hours, as well as at other 
periods of the day. The cold bath strengthens the heart and in- 
creases the excretion by the kidneys of typhotoxines (Roque and 
Weill). 

Where reaction is slow to establish itself, a tablespoon or two of 
whiskey diluted should be given to the patient both before and after 
the bath. The cold bath reduces the temperature two or three de- 
grees, as a rule, and brings it down often to the normal, sometimes to 
subnormal grades, where it will likely remain for an hour or two. 
To be effective it must, as stated, be repeated throughout the day 
and night. Cold baths and alcohol make now almost routine prac- 
tice. Both give comfort and safety. There must be care with 
chloral in late stages of the disease. 

Peritonitis, whether from perforation or not, haemorrhage, con- 
stitute about the only contra-indications. So far from increasing, it 
has been proven that the cold bath actually lessens the liability to 
haemorrhage of the bowels. No remedy that we possess secures the 
advantages and avoids the disadvantages of antipyresis so effectually 
as the cold bath. The cold bath is sometimes impracticable and 
impossible, whether from prejudice, absence of apparatus, or condi- 
tion of body, and in these cases resort must be had to other agents. 
Sponge baths and wet sheets are poor substitutes for the bath. The 
safest of the modern antipyretics is phenacetin, which is best given 
in a large dose, three grains to a child, five grains in adolescence, 
ten grains to an adult, at the height of the temperature, which it 
will reduce, in the course of fifteen or twenty minutes, a degree or 
two, with some slight sweating, which in turn aids in sustaining the 
antipyresis. Antipyrin or antifebrin in half the dose of phenacetin 
secures the same advantages, but with a more depressing effect upon 
the heart. These depressions may be counteracted by alcohol, whis- 



TYPHOID FEVER. 283 

key, a teaspoonful to a tablespoonf ul diluted, in which case there is 
not much choice between the remedies. Aconite and veratrum, on 
account of damage to the heart, are no longer given in typhoid fever 
except in infinitesimal doses, tit aliquid faciat, in which case they 
may be better substituted by dilute hydrochloric acid, gtt. ij.-v., di- 
luted in a tablespoon or wineglass of water. The modern antipy- 
retics have the additional advantage that they possess some anodyne 
properties and thus allay insomnia, headache, neuralgic pains, while 
they reduce fever. A dose of phenacetin used with judgment at the 
proper time will give comfort in the course of typhoid fever. 

The time for stimulation arrives in the course of nearly every 
case of typhoid fever. This time is indicated, first, by the character 
of the pulse, which begins to flag in its force. Perhaps the first 
signal of its weakness is shown in the condition known as dicrotism, 
or reduplication at the radial pulse. The force of the heart is 
estimated readily also by the degree of compression necessary to 
obliterate the pulse with the finger. The degree of weakening or 
faintness of the pulse, which follows the lifting of the right arm at 
right angles to the body, indicates its strength. 

Alcohol is the best whip for a flagging heart — in a mild case in 
the form of wine, especially sherry or Madeira; in a severe case in 
i}he form of whiskey, which may be given as milk punch or as a cold 
drink with ice water, or, as it may be made more palatable by the 
addition of sugar and lemon juice or some bitter (tincture of mix 
vomica), as a cocktail. In the most prostrated cases the alcohol 
should be in the form of brandy. A threatened collapse may be 
bridged over by a cup of black coffee with a teaspoonful of cognac, 
or resort in the extreme cases must be had to the analeptics, as the 
oil of camphor 1 : 10, or tincture of camphor or musk. Whiskey 
may be injected into the bowel or administered subcutaneously. 
Nitroglycerin 1 : 100, in dose of gtt. i.-iij. in whiskey, is one of the 
most powerful agents we possess. It may be administered also in 
"the same dose under the skin. It is especially indicated when the 
urine is scant. 

Diarrhoea seldom calls for treatment. A moderate diarrhoea be- 
longs to typhoid fever and should be let alone. It carries off noxious 
matter. Excessive diarrhoea is best restrained by bismuth gr. x.-xx., 
lime water with milk, or by a small dose of the camphorated or 
simple tincture of opium; or, 

B Acidi hydrochlorici diluti , gtt. xl. 

Tincturas opii gtt. xl.-lx. 

Aquae camphorse ad I iv. 

M. S. Tablespoonful every two to six hours. 

A dry tongue with sordes and muttering delirium is an indication 



284 MALARIA. 

for turpentine gtt. x.-xx. in milk, or hydronaphthol gr. v. every two 
to four hours. 

Constipation belongs often to the first week of the disease, and 
disappears of itself later without treatment. Should it become 
troublesome it may be relieved by enemata rather than by drugs. 
Protracted constipation is due, as a rule, to error in diet, more espe- 
cially to too long-continued or exclusive use of milk, and may be 
often counteracted by the substitution of other fluid food. Calomel, 
gr. i.-iij., is never harmful in the first week, when it sometimes 
clears up comatose states. 

Complications call for treatment according to their character. 
Haemorrhage demands more absolute rest and the avoidance of all 
food. Ice dissolved in the mouth may relieve or lessen thirst. Ice 
bags may be put over the belly at the region of the ileo-caecal valve. 
Peristalsis should be arrested by opium. ~No form is better here 
than the simple tincture gtt. x.-xx., or camphorated tincture 3i., 
repeated as may be deemed necessary. Ergo tin, or preferably scle- 
rotinic acid, in syringeful doses, may be injected under the skin of 
the abdomen every fifteen to thirty minutes. Rescue may be had 
at times by transfusion of warm salt water, one drachm to the 
pint, the water having been previously boiled. Subcutaneous injec- 
tion sometimes suffices as well as intravenous, without its dangers. 
Perforation calls for opium almost up to narcosis. In the light of 
present evidence it is quite justifiable to cut down upon the intestine 
in the hope of finding the seat of perforation or source of excessive 
haemorrhage. But let medicine be not brought into disrepute by 
surgery in articulo mortis ! The convalescence is long. It is often 
pleasant, sometimes tedious, and always subject to relapse. It is 
impossible to exercise too much restraint in the matter of diet and 
muscular effort in the earlier period of convalescence. Patients in 
typhoid fever should only very gradually get upon their feet. 

The dilute hydrochloric acid, five to ten drops in a wineglass of 
water before meals, best aids the digestion of food taken, with, as a 
rule, an appetite increased to voracity, whereby the patient often 
gains a pound a day. It is common observation that patients have 
a more robust health and vigorous intellect, possibly from the de- 
struction of some previous poison, probably on account of the long 
rest of mind and body, after typhoid fever than ever before. 



MALARIA. 

Malaria (mal-aria, bad air); ague; German, Wechselfieber. — A 
disease caused by infection of the blood, especially the red blood cor- 
puscles, by certain animal organisms (protozoa) ; marked in typical 



MALARIA. 285 

cases by attacks of chill, fever, and sweat, in irregular cases by neu- 
ralgias and various nervous phenomena, and in more protracted cases 
by marasmus and enlargement of the spleen. The predominating 
element in symptomatology of whatever character is periodicity, 
with intervals of more or less complete absence of symptoms. The 
pathogenic micro-organisms disappear from the blood and the symp- 
toms of the disease subside under the influence of quinia. 

History. — Forms of malaria were known in the most ancient 
times. Protagoras described the drowsiness and coma of pernicious 
fever. Celsus recognized the quotidian, tertian, and quartan types. 
Archigenes observed various masked forms, and Rhazes put upon 
record cases in which one attack followed so close upon another as to 
constitute the subintrant form. 

Rome was early the seat of malarious disease. The waters which 
poured down from the Palatine, Aventine, and Tarpeian hills 
formed marshes, emanations from which developed the disease. The 
elder Tarquin drained Rome with subterranean sewers — which, from 
their extent, Pliny likened to subterranean streets — with the effect of 
freeing the city from malaria to such an extent that, by the time of 
the Csesars, Rome contained more people than any city before or for 
centuries after. With the invasion of the Goths the sewers were 
blocked and Rome again became a centre of malaria. The country 
about Rome, the Pontine marshes, have long been famous as hotbeds 
of malaria. Appius Claudius drained the marshes into the Tiber, 
built bridges and the celebrated Way, which still remains, so that 
the country became the seat of an extensive population. Under 
Theodoric the drains were broken up, plains were converted into 
marshes, and the Maremma became malarious to such degree as to 
render it, as it yet remains, practically uninhabitable. The cause 
(Plasmodium) of malaria was discovered by Laveran (1881). 

Etiology. — From all time it has been recognized that marshes 
breed malaria. Ever since the days of Hippocrates it was remarked 
that while the average mortality is one in thirty-four, that in marshy 
countries is one in twenty. Marshes are to be found in nearly 
every country. In India, one hundred and eighty- four square miles 
south of Calcutta, lies the vast marsh of the Sunderbund, twenty 
thousand square miles in extent, a breeding place for malaria as well 
as cholera. The deltas and embouchures of rivers spread with their 
detritus marshes over vast areas: thus in China at the mouths of the 
Blue and Yellow Rivers: in Africa, of the Orange, Zais, and Zam- 
besi: in South America, the Amazon. Orinoco, Rio del Xorte: Eng- 
land has its fens of Lincolnshire and Xorfolk. In our own country 
the swamps and bayous overflowed and bared annually by the large 
Western and Southern rivers are perpetual homes of malaria. Per- 



286 MALARIA. 

haps nowhere upon earth do the conditions exist that produce the 
disease in such virulence and constancy as in Central America, 
where workmen upon the great canals have to be substituted every 
few months. 

Heat, moisture, and vegetable decomposition are the factors rec- 
ognized as essential to the production of malaria, so that the disease 
finds its limit, on account of temperature alone, at 63° North and 57° 
South latitude. The cause of the disease is heavy and hugs the 
ground. It may be transported by winds, but, as a rule, altitude 
exempts from malaria. This altitude must be greater in proportion 
as the malarial infection is most intense. It must be greater and 
greater toward the equator. Near Rome is the elevation of Tivoli,. 
one hundred and sixty-five yards perpendicular height, where mal- 
aria still exists, but in much less intense degree; beyond is Monte 
Mario, two hundred and thirty yards, where fewer and fewer cases 
are found; while further off is Serre, three hundred and twenty yards,, 
absolutely free of malaria. 

It is estimated, as a rule, that the necessary altitude to secure 
exemption is, in Italy, ten or eleven hundred feet; in the Pyrenees, 
five thousand feet; in Ceylon, sixty-five hundred feet ; and in Peru,, 
ten thousand feet. The limit to which the disease can be transported 
by the wind is estimated best at sea. The crews of ships off the 
coast of Africa secure exemption at a distance of about three thou- 
sand feet, and about the same distance is observed, in malarious sea- 
sons, off the rocks of Gibraltar. So well recognized is the fact of 
altitudinal exemption that the inhabitants of intensely malarious 
countries build their houses above the level of the ground. Thus at 
Demerara the natives build their huts on corn stalks to lift them 
above the surface. Soldiers in these countries are not permitted to 
sleep on the ground floor of barracks. 

It is the relative rather than the absolute humidity which deter- 
mines in certain places the production of the disease. Thus in the 
perfectly dry island of Barbadoes malaria prevails only when the 
rain falls, a greater part of the year; while in Trinidad, unless the 
rain falls a greater part of the year, malaria is developed. In Bar- 
badoes any diminution of the rainfall is drunk up and disposed of by 
the soil, while in Trinidad a diminution of rainfall lays bare vast 
tracts of marsh otherwise covered with water. The rocks of Gib- 
raltar and the rocks about the Orinoco, considerable elevations, are 
nevertheless hotbeds of malaria, because the springs which prevail 
in these places feed the vegetation which forms in fissures and cre- 
vices, and, with the abundant moisture and great heat, furnish the 
requisites for malaria. Malaria has developed also an intensity in 
sandy plains, as in the English army at Rosendaal. In these cases 



MALARIA. 287 

water may be found at any place a foot or so beneath the excessively 
dry surface. The subsoil is really detritus, vegetation originally 
brought down by the Rhine and Waal, and covered by the winds 
with find sand, the silt of the sea. These are, therefore, apparent 
and not real exceptions. 

On the other hand, there are places upon the earth where all the 
necessary conditions seem to exist and yet malaria is absent. Before 
the gates of Mexico lies the great lake of Tescudo, twenty-five square 
miles in extent, stagnant, brackish, with abundant decomposing vege- 
tation, subject to the heat of a tropical sun, and yet developing little 
or no malaria. The same thing has been seen in certain islands of the 
Pacific, in swamp lands of Australia, Asia, and notably, curious as 
it may seem, in the well-known marshes of the Emerald Isle. Here 
are heat, moisture, and vegetable decomposition, but, for some unex- 
plained reason as yet, no malaria. Liebermeister ventures an expla- 
nation to the effect that the cause has not yet been carried there. 
Perhaps there may be discovered other conditions which prevent its 
growth. 

Obstacle is sometimes offered to the transmission of the infection 
by interposing trees. Malaria prevailed at Villatri until it was in- 
tercepted by the growth of a grove of trees, which Pope Benedict 
XIY. afterward cut down to expose the place to new infection. The 
ancient temples of medicine, which were sanatoria, were situated on 
islands and surrounded by trees. The indigo planters are not afraid 
to dump the refuse of the plant after the extraction of its coloring 
matter, hotbeds of malaria, in close proximity to their houses, pro- 
vided there intervene a grove of trees. 

As marshes become drained, more especially as cities are built, 
streets paved, sewers constructed, places and towns previously un- 
healthy become habitable. Hippocrates says of Abydos that it was 
freed from malaria in this way. Sydenham declares that in his time 
one to two thousand people died every year in London. At the pre- 
sent time it is difficult to find a case. So it is noticed in our own 
country that cases seldom or never develop in the city proper, but in 
the suburbs and outlying districts, more especially in the valleys of 
rivers after the recession of overflows. 

Malaria has for a long time been supposed to be caused by a con- 
tagium vivum, with no other positive proof, however, than the 
isolated experiments of Gerhardt, of Berlin, who succeeded in pro- 
ducing the disease by injecting blood from the spleen of an affected 
individual into the veins of a healthy man. All efforts to discover 
any demonstrable and acceptable cause of the disease remained 
futile up to the time of the investigations of Laveran (1881), a 
French military surgeon of Algiers, who succeeded in discovering 



•288 



MALARIA. 



in the red blood corpuscles peculiar amoeboid bodies endowed with 
characteristic protoplasmic motion and containing granules of pig- 
ment matter (vide Frontispiece, Fig. 2). Certain smaller bodies of ir- 
regular, semilunar, crescentic outline are also found in the blood 
plasma, connected together often by fine threads. These bodies are 
present in the blood of malaria in greatest abundance during a chill, 
and disappear to a great extent after the attack. Many of them are 



, IffUilainsHiigsssfssgHissilli 




m( - 



SMS«|:i.^: - 



Fig 155 —Temperature curve in man after injection of blood from patient affected with mal- 
arial (quartan) fever : x 12, noon, injection of four cubic centimetres blood ; + injection of two 
grammes of muriate of quinia (Bacelli). 

clear, more or less spherical, sometimes flagellated, hyaline masses, 
undiscoverable without the use of dyes. They gradually increase in 
size until they fill the body of the corpuscle, during which process they 
undergo peculiar segmentation. The intracorpuscular body receives 
the name plasmodium. Besides the plasmodium, flagellate structures 
with three to eight long, active cilia may be seen floating free in the 
blood of more acute cases, or may be discovered more especially in 
blood withdrawn from the spleen, which is regarded as the hotbed 




Fig. 156.— Plasmodium malarias : a, b, c, intracorpuscular bodies ; g, crescent ; h, flagella. 

of malaria in the body. Golgi claims that the various types of fever, 
anomalies, etc. , depend upon peculiarities or differences in these pa- 
rasites, and Laveran maintains that the crescentic forms are found 
only in inveterate and cachectic cases. So, too, it is said that qui- 
nine destroys only the plasmodium, and that arsenic has more effect 
upon the crescentic form. Concentrated aqueous solutions of fuchsin 



MALARIA. 289 

and methylene hlue are the best staining agents for ordinary diag- 
nosis. Fine double colorings are made with eosin concentrated solu- 
tion in glycerin, with two to five per cent absolute alcohol, and sub- 
sequent stain with methylene blue. The specimen, after five to ten 
minutes in each staining, is washed off and preserved in balsam. 
After this method the red corpuscles are colored pale red, the nuclei of 
the white blood corpuscles pale blue, and the parasites a deep blue. 
The blood is best examined as taken fresh, at the height of fever, from 
a drop after puncture of the end of a finger, upon a cover glass which 
is at once covered by another glass, put under the microscope and 
stained, when the amoeboid bodies show themselves in abundance. 
These bodies disappear after the administration of quinine and 
arsenic, hence they may not be found in subjects under treatment. 
Variations in the type of the disease — quotidian, tertian, and quar- 
tan — are believed to correspond to varieties in the life history of 
these structures. As they are found always in malaria, and only in 
malaria, and disappear from the blood with the cure of the disease 
spontaneously or artificially, they are believed to be the cause of the 
disease ; but as they have not been discovered out of the body, and 
as they may not be cultivated in special soils, the mode of ingress is 
not known. It is probable that these bodies, as such, or in prelimi- 
nary stage of development, originate in water ; that they are then 
taken up by the air and inhaled into the body of man. It is known 
that the disease has resulted distinctly from drinking-water, as well 
as from air. An instructive illustration of this fact is found in the 
statement of Baudin, who reported the infection of a number of 
soldiers by the use of drinking-water. The soldiers were being 
transported from Algiers to Marseilles. From some oversight the 
water supply was neglected and had to be taken in at a swampy 
place known as Bona. The crew had their own water, and nine of 
the soldiers used only the water of the crew. The crew remained 
entirely unaffected, as did also the nine soldiers, while all the rest, 
without exception, were taken sick with the disease. Probably 
ma] aqua is a name as appropriate as malaria. But in the vast 
majority of cases the disease is inhaled. Abundant proof of this 
fact is established by direct observation. Experimenters have ex- 
posed themselves for hours, have gone to sleep or spent the night in 
proximity or in the midst of a marsh, to be taken, in the course of a 
few hours, with characteristic symptoms of the disease. 

Malaria presents itself in a varied picture of forms so different as 
to seem to belong to different affections, but all resolvable into mal- 
aria by the periodicity of symptoms or by the success of treatment. 

The forms which are now recognized are : 

1. Intermittent fever with distinct interval. 
19 



290 MALARIA. 

2. Remittent or continuous fever, where the interval is short or 
nearly absent. 

3. Masked malaria, with an infinitely varied symptomatology. 

4. Pernicious malaria, with grave symptoms of blood poisoning. 

5. Malarial cachexia. 

Intermittent fever begins with a chill, which distinguishes itself 
by its severity, in which regard it is equalled only by that which 
announces croupous pneumonia and cerebro- spinal meningitis. The 
cold is so severe as to make the teeth chatter and agitate the body in 
those violent shivering movements which constitute a chill. The 
temperature rises during the chill to 104°, even to 105°, and is not 
^ increased more than half to one degree during the subsequent fever. 
Yet the surface of the body remains distinctly cold. The nose is 
pinched, the eyes are sunken, the cheeks, the tip of the nose, the 
lobes of the ear are cold, the surface is tinged blue. There is cutis 
anserina. Cold sensations shoot out from the spinal column through 
the trunk to the extremities, and ma} T not be overcome or subdued at 
first by approach to the fire or by any amount of clothing. In bad 
cases there are, at this stage, signs of distinct collapse : the heart's 
action becomes feeble, the pulse nutters, there is profound prostra- 
tion of strength and almost entire abolition of the voice. In the 
course of half an hour to two hours the chill gives place to a second 
stage, the fever. Sensations of heat now shoot out from the spine, 
at first as agreeable substitutes for the extreme cold. For a time 
flashes of heat and shivering fits may alternate. Soon the heat 
assumes the mastery ; the surface is supplied with blood, the face 
becomes flushed, the eyes are reddened, the vessels throb, the pulse 
bounds. The heart's action visibly agitates the chest. The heat 
becomes now so excessive as to be far from agreeable, and associated 
with it is more or less violent, beating headache. The skin is dry 
and hot, the mouth is parched, there is great thirst. The secretions 
seem all dried up. In this condition of extreme distress the patient 
remains from two to four hours, when the heat begins gradually to 
subside. The attack is passing over now into the third stage, the 
siveat. 

Perspiration presents itself at first about the chest, but extends 
gradually over the body. It is especially abundant about the neck 
and flexures of the joints ; it stands out in beads at last, and, ac- 
cumulating, trickles down upon the face. Gradually the extreme 
heat begins to abate. Under the evaporation of the excessive 
amount of fluid the surface cools, the head ceases to ache, the ves- 
sels to throb, the heart to bound. The sweating stage lasts again 
from half an hour to two hours. It is, as a rule, the shortest of the 
three stages of the disease. The patient now falls into comfortable 






MALARIA. 



291 



slumber, or is able, feeling somewhat languid or relaxed, to resume 
his occupation. 

The scene repeats itself in twenty-four, forty-eight, or seventy - 





Fig. 157.— Quotidian fever (Seguin) • 



Fig. LIS.— Tertian fever (Seguin). 




illlillllllil 

'inn i 

HHI 
Blii 




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two hours, to constitute quotidian, tertian, and quartan types of the 
disease. The tertian is by far the most frequent type. It is probable 
that the quotidian and quartan 
are modifications of the tertian 
type. The tertian type shows it- 
self most frequently between the 
hours of 10 A.M. and 2 p.m., but 
may occur at any hour of the day 
or night. Attacks earlier or later 
than usual are said to anticipate, 
or postpone, forms, respectively, 
of increasing and decreasing se- 
verity. Double tertians and dou- 
ble quartans precipitate or other- 
wise disturb the regular order 
of events to such degree, at 
times, as to embarrass diagnosis. 
In children an attack of in- 
termittent fever varies in several 
points : 1. For the most part the 
chill is wanting. The child be- 
comes drowsy or sleepy, dull; the surface becomes cold : the nose 






Fig. 159.— Quartan fever (Seguin). 



292 MALARIA., 

and extremities may even become blue, but there is no convulsive 
agitation. In the majority of cases the attack is announced with 
the onset of the fever. The picture does not vary in fever from that 
of an adult, save that, 2, children easily suffer delirium and may 
become more or less comatose. 3. The sweating stage may be want- 
ing entirely, or, if present, is never so abundant or long continued. 

As the intermissions become less and less marked the disease 
finally presents the form of a remittent fever. Fever now never 
entirely abates throughout the whole course of the twenty-four 
hours, but there may be noticed during the early hours of the morn- 
ing a more or less distinct remission of symptoms and fall of tem- 
perature of one to three degrees, with corresponding improvement in 
the subjective condition. In remittent fever the attack distinguishes 
itself by prominence of symptoms on the part of the digestive sys- 
tem. There is gastro-intestinal, more especially duodenal ca- 
tarrh. The tongue is more or less heavily coated * there is more 
marked anorexia and nausea ; vomiting is more persistent and 
troublesome. Many cases are marked by jaundice; the conjunctiva 
is tinted. The skin assumes a distinct yellowish hue. There is also 
pronounced constipation. These are the attacks that the old writers 
called bilious fever. As the disease becomes more and more con- 
tinuous it comes to finally assume the picture of typhoid fever. 
There is, along with the gastric, more and more nervous depression, 
more and more stupor or headache, so that at times the diagnosis 
is not easily distinguished from that of typhoid fever. Hcematuria 
is a complication which occasionally occurs in these cases. This 
accident is much more frequent in the more intensely malarious 
countries, but occurs occasionally everywhere. In the temperate 
zone hematuria should first excite the suspicion of malarial fever. 
As a rule it yields readily to quinia. 

Masked malaria shows itself under a multitude of forms, the chief 
of which is neuralgia. Under whatever form, masked malaria is 
usually quotidian in type. The affection sets in in the earlier hours 
of the morning and ceases toward the close of the afternoon. The 
supra-orbital nerves are picked upon by special preference. Supra- 
orbital neuralgia is of malarial origin in the majority of cases. This 
is the brow ague, or, from its occurrence during the day and absence 
at night, the " sun pain" of old people. The occipital nerves rank 
second in the order of attack — pain in the back of the head, with the 
dull depression that distinguishes malarial poisonings. It sets in 
about 10 o'clock in the morning, to remain with the patient through- 
out the day. The intercostal nerves are attacked in the same way, 
to be distinguished at times from other intercostal neuralgia, or 
affection of deeper seated organs, only by the therapeutic test. 



MALARIA. 293 

Sciatica has malarial origin rather as an exception, neuralgia of 
this nerve arising generally from other causes. Various parsesthesise, 
more rarely ansesthesise, may likewise depend upon malarial cause, 
and be recognized bj^ periodicity of occurrence and rapid relief under 
the use of quinia. Malaria may also simulate pneumonia and pleu- 
risy, affection of the kidney and bladder. There are malarial dysen- 
teries and diarrhoeas, malarial coryzas and catarrhs. There are cases 
of malarial hydrophobia and tetanus, night blindness, etc. Curiosi- 
ties of all kinds may be found in the case books, dependent upon 
malaria as proven in the same way. It may be said that as the 
malarial poison becomes less and less intense, in cities, for instance, 
as distinguished from country places, the masked forms of malaria, 
which are the milder forms, predominate. The general rule holds 
good for all diseases or for any affection which shows more or less 
distinct periodicity of occurrence. It probably depends upon mal- 
arial cause. Thus dyspepsias and dysenteries which have defied 
all kinds of local treatment for months or years have yielded quickly 
and permanently to specific treatment. At the same time it must be 
admitted that the element of periodicity is not so distinct in our day 
as formerly. In the first place, the disease itself is milder. It may 
be assumed that less of the cause has been ingested or inhaled, or 
that in most cases the course of the disease has been interrupted or 
disturbed by treatment, so that the typical periodicity is not so easily 
elicited. But doubt alone justifies a trial of the therapeutic test. 
Of these cases it is said that the diagnosis is made ex juvantibus. 
Thus also it is made plain that many affections, especially neuralgias, 
of periodic occurrence or recurrence, are not necessarily malarial, are 
rather rheumatic in that they yield sooner to the salicylates than to 
quinine. 

Pernicious malaria is that form in which either an enormous 
amount of the poison has been received into the body, or the body 
itself has been greatly debilitated. in the course of the disease or by 
other maladies. Pernicious malaria shows itself, therefore, most in 
the unacclimatized, who are always peculiarly susceptible. It never 
occurs with the first, but shows itself in the second or third attack. 
It is announced with a chill, or with the second or third attack of 
quotidian, tertian, or quartan form, and presents itself also in variety 
of form. The most common is the comatose form, in which, under 
the chill, the patient falls into fever, stupor, and coma. The face is 
deeply flushed, the conjunctivae congested ; the pupils, dilated or con- 
tracted, are irresponsive to light ; the cheeks flap in respiration ; there 
is stertorous breathing, general abolition of all sense, sensation, and 
motion, as in the picture of cerebral haemorrhage. 

A marked contrast to it is the so-called algid form, in which 



294 MALARIA. 

there is profound collapse, feeble, fluttering pulse, cold surface 
covered with a clammy sweat, as in the picture of a protracted 
syncope. 

Pernicious malaria is sometimes manifested also in the convulsive 
form. Fits, which closely resemble attacks of eclampsia, agitate 
the body, or assume at times the aspect of hydrophobia with its- 
dread of water and terrible anxiety ; or of tetanus, with fixation of 
the jaw, rigid contraction of the muscles of the body, sometimes 
with complete opisthotonos. 

Malarial cachexia shows itself in individuals, long residents of a 
malarial climate, who have become to a degree acclimatized. In 
^these cases the blood may be said to be saturated with malarial poi- 
son, to the degradation of the strength, physical and mental. These 
individuals show the picture, more or less pronounced, of marasmus. 
There is emaciation with the prostration ; the complexion is sallow, 
the eyes sunken, the expression listless, apathetic. Perhaps the 
most marked bodily change to be discovered in these cases is distinct 
enlargement of the spleen, which, in the form of "ague cake," may 
be increased from five to fifteen times its natural size, to largely, or 
apparently entirely, fill up the abdominal cavity. These subjects 
are continual sufferers from irregular chills and fever, with head- 
ache, neuralgias, and the various masked forms of the disease. The 
poison which accumulates in the blood and spleen may manifest 
itself in almost any organ at any time. 

The diagnosis rests upon the periodicity of attack, the intermis- 
sions or remissions (as determined by the thermometer in the hours 
of early morning), the enlargement of the spleen, and, in doubtful 
cases, the examination of the blood. Laveran found the parasite 
four hundred and thirty -two times in four hundred and eighty ob- 
servations. 

The prognosis has entirely changed for the better since the dis- 
covery of quinia — in fact, since the discovery of cinchona, in 1640, 
when the first specimen was brought to Spain from Peru by the 
Count of Cinchon, the Spanish Viceroy, and his body physician, 
Juan del Vego. Not much distinct progress was made, however, in 
the treatment of the disease until the time of Sydenham, who 
adopted the practice suggested by a druggist's clerk, Robert Talbor, 
of Cambridge, to dissolve the bark in alcohol (making a tincture, in 
other words), and administering the remedy close upon the heels of 
the previous, to prevent a future, attack. This treatment was per- 
fected by the discovery of quinia by Pelletier, since which time the 
bark itself has been only rarely employed. All question of discus- 
sion regarding the treatment of malaria revolves now about dosage 
and time of administration. It is now common and the best prac- 



MALARIA. 295 

tice to administer the remedy before the attack, and, as quinine has 
its maximum effect five hours after administration, it is given so 
that this effect shall coincide with the onset of the attack. An adult 
requires twenty-five to thirty grains, a child five to fifteen grains, to 
prevent attack. It is best given in pill, capsule, or wafer, and to 
children in powder with milk, in broken doses, taken in the course of 
half to one hour. Quinine is one of the remedies which may be 
given with nearly equal efficacy in the same doses per rectum. But 
quinine may fail, for two reasons — one, that the remedy may not be 
absorbed ; another, that after long use tolerance is begotten. These 
evils may be avoided by the administration of the remedy per rec- 
tum or subcutaneously. For such use the neutral bromide is to be 
preferred, as all acids irritate the skin. Care must be taken to keep 
the solution hot. The test tube, the spoon, and the syringe must all 
be kept warm, and the drug, in the ordinary dose of five grains to 
the maximum dose of ten grains, must be injected under the skin of 
the back deep into the subcutaneous tissues. Quinine may be used 
in this way in only the most exceptional cases, as, for instance, in 
pernicious malaria, where no time may be lost in addressing the 
cause of the disease. 

The use of arsenic in malaria dates from the last century. It 
was first employed by charlatans under the name of " ague drops," 
and came into general use only when Fowler prepared a solution by 
which the quantity of the drug could be easily graduated and ad- 
ministered without danger. Arsenic is adapted especially to the 
cases of chronic malaria, malarial cachexia, and masked forms ob- 
stinate to quinia. The remedy is best given in the form of Fowler's 
solution, gtt. ij.-v. after each meal, to be increased daily to tole- 
rance, as manifest in puffiness of the eyelids, pain in the bowels, or 
diarrhoea. Upon the occurrence of either of these signs the remedy 
is to be discontinued at once. Should it be deemed necessary to con- 
tinue the dose in larger quantity, the pain and the diarrhoea may be 
prevented by the simultaneous use of a few drops of the tincture of 
opium. 

Under the use of quinia and arsenic the protozoa which cause the 
disease disappear from the blood, but to secure permanent disap- 
pearance it is necessary that the remedy shall be continued in grad- 
ually diminished doses for at least a week after the subsidence of all 
symptoms. 

As methylene blue has been observed to have the same effect 
upon the plasmodium malaria?, this remedy has been tried success- 
fully by Guttman and Ehrlicli. Doses of one to one and one-half 
grains of pure medicinal methylene blue, administered in capsule to 
prevent staining the mouth, every two hours for one or two days, 



296 



YELLOW FEVER. 



rid the blood of protozoa and break up the attacks of the disease. 
The remedy sometimes causes severe dysuria and has no advantage 
over quinia. Obstinate cases demand change of climate. 



YELLOW FEVER. 

Yellow fever ; Spanish, vomit o negro (black vomit). — An acute 
infection of tropical coast towns, characterized by fever, which shows 
itself in stages of access, subsidence (stage of calm), and renewal 
(stage of reaction), icterus, albuminuria, hsematemesis (black vomit), 
and rapid and profound prostration. 

History, Geography, etc. — Yellow fever is indigenous in cer- 























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Fig. 160.— Temperature chart, yellow fever; mild case 

tain parts of the tropics — West Africa, where it is believed to have 
originated ; West Indies (Antilles), first in 1647 ; Mexico in 1699 — 
and is thence disseminated along lines of travel by sea to seaport 
towns or towns in direct (river) communication with the sea. 

It is nowhere indigenous in our country, and dies out every win- 
ter on the advent of frost. Hence it must be freshly imported, un- 
less infected matter be held over under favoring circumstances, as at 
Memphis, 1879, where it had hibernated from the previous year. 

It reached the United States first at Boston in 1693, and has since 
occurred and prevailed at various places and periods — sometimes as a 
mild endemic, sometimes as a devastating epidemic — up to the present 



YELLOW FEVER. 



297 



time. Thus in Philadelphia in 1793, of 11,000 cases, 4,040 fell victims 
to the disease ; in the epidemic of 1853 at New Orleans the mortal- 
ity was 7,970, and in that of Memphis in 1873 the deaths numbered 
2,000. The disease has been carried as far north as Portsmouth, 
New Hampshire (1798), and has penetrated to the interior by refugees 
as far as Cincinnati and Gallipolis (1887). The highest altitude 
(seven hundred and forty-five feet above the level of the sea) was 
reached at Chattanooga, Tennessee (1878). The famous College of 
Physicians of Philadelphia first (1797) promulgated the view that the 
disease is always of foreign origin and should be barred out by quar- 
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Fig. 161.— Temperature chart, yellow fever; typical severe case. 

Hoche, Philadelphia (1793) ; the most thorough studies of etiology by 
Sternberg, Surgeon U. S. A., Washington (1890). 

Etiology. — Yellow fever comes only from without, and is pre- 
sumptively caused by a micro-organism which, despite claims to the 
contrary, has not yet been isolated. The disease requires for develop- 
ment a certain temperature (75° F.) and moisture. It is not directly 
contagious, and is chiefly conveyed by things (fomites), especially 
by baggage and bedding of patients, and bilge water of ships carry- 
ing cases of the disease. The acclimatized have a degree of immu- 
nity which is lost by change of residence to regions never visited by 



298 



YELLOW FEVER. 



the disease. The colored races, Africans, Creoles, have a certain im- 
munity and lessened mortality. One attack confers immunity, as a 
rule. 

Symptoms. — The incubation is short, from one to five days* 
This period is usually wholly free of symptoms. In exceptional 
cases malaise, anorexia, headache, vertigo, pain in the back, fatigue 
with tendency to sweat, may show themselves as prodromata. 

As a rule the onset is sudden, with a chill, attended and followed 
by fever, frontal headache, and heavy rheumatic pains. Pains in 
the loins and legs may be excruciating in severity. The face is 
flushed, the eyes shine and are intolerant to light. "The dusky 

2><xy of D'-sease, 



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Fig. 162.— Temperature chart, yellow fever ; protracted case. 



face with the deep suffusion of the eyes in severe cases is quite char- 
acteristic " (Sternberg) . The pulse, full and strong at first, is reduced 
in frequency and force, often during the height of the fever, and 
always in the stage of calm, when it may fall from 100-120 to 40-30 
in the minute. 

The cardinal symptoms of yellow fever are three — viz., the fever, 
the icterus, the vomit. These symptoms have given the name to the 
disease. 

The fever is peculiar, in that it consists of but a single paroxysm 



YELLOW FEVER. 



299 



with a break in its gradual fall. The temperature is highest at the 
start and falls at once, and to such degree that the first few days only 
are considered febrile. 

Hereupon ensues the stage of calm, a period nearly or quite free 
of fever, but marked by profound prostration. The stage of calm, 
like the stage of fever, lasts from a few hours to a few days, and is 
followed by the reaction with fever of remittent type. The accom- 
panying charts (Figs. 160-162) from Sternberg's account record the 
run of the temperature in a mild, a protracted, and a severe case. 

The icterus, which may be entirely absent, usually shows itself 
about the third day, and varies in degree from a faint yellowish 
tinge to a deep mahogany hue. When absent from the skin it may 
be still seen in the conjunctivae, where it often makes striking con- 








Fig. 163. —Liver cells in yellow fever with Fig. 164.— Streptococcus from vomit (not black) 

necrotic masses in and between the liver of yellow fever (Sternberg), 
cells (Sternberg). 



trasts in the colored race; in a fatal case it may show itself only 
post mortem. The icterus is due to rapid disorganization of the liver 
and reabsorption of bile. The symptoms largely revolve about the 
condition of the liver, which is found on autopsy to have suffered 
acute parenchymatous with fatty change without sensible atrophy. 
Products of this degeneration, as well as of the kidney, which shows 
the same process, poison the blood and produce in the last stages of 
the disease symptoms of uraemia, the cholera typhoid with coma. 

Gastric distress, vomiting, as a sign of toxaemia, belongs to all 
the grave infections, but is especially frequent and severe in yellow 
fever. The black vomit is blood from haemorrhage by diapedesis 



300 YELLOW FEVER. 

through paretic vessel walls. It shows itself in the graver cases in 
the course of the first days, but is often entirely absent even in fatal 
cases of the disease. Haemorrhage may occur also from other mu- 
cosae, as from the mouth and nose (epistaxis), more rarely from the 
stomach, intestine, bladder, uterus, etc. 

The urine is scanty and dark, in bad cases suppressed, and al- 
ways contains albumin as one of the main features of the disease. 
The mind is usually clear but indifferent. Consciousness is main- 
tained with apathy. Delirium is not common, though the scene 
usually closes with coma. 

The diagnosis rests upon, 1, the existence of the disease in the 
community, or knowledge of its importation; 2, the albuminuria, 
which in its presence or abundance helps to distinguish yellow from 
remittent (malarial) fever; 3, the character of the fever with its 
stages; 4, the icterus; 5, the coffee-ground or black vomit. Yellow 
fever is distinguished from dengue by the fever (stages), as well as 
by the predominant or persistent pains of dengue, and from typhoid 
by the mental state, fever, and abdominal signs of typhoid fever. 

The prognosis is always grave, and is based upon the intensity of 
individual signs, the amount of albuminuria, the degree of fever and 
of jaundice, etc. Black vomit is ominous, but is by no means of 
necessity fatal. The mortality ranges from ten per cent with the 
acclimatized, to eighty per cent with those not thus protected. Three- 
fourths of the deaths occur in the first week of the disease. 

Prophylaxis consists in the quarantine of ships carrying cases 
of the disease. Land quarantine is useless. Camp life in healthy 
places is the best protection during prevalence of epidemics. 

The treatment is symptomatic. It is considered good practice to 
open the bowels freely at the start with calomel or castor oil, but bad 
practice to continue purgation. Fever is best allayed by sponge 
baths and phenacetin gr. v.-x. ; irritability of the stomach by cracked 
ice, bicarbonate of soda gr. x.-xx., best in soda or Selters water, or 
hy chloral gr. ij.-v. in peppermint water. 

To counteract the excessive acidity of the various secretions, 
Sternberg suggested the use of sublimate with the bicarbonate of 
soda as an alkaline antiseptic. After favorable reports from exten- 
sive trial, the combination was improved as follows: 

ty Sodii bicarbonatis 3 iv. 

Hydrargyri bicbloridis , gr. ss. 

Aquse purae O ij. 

M. 

For a severe case two tablespoonfuls every hour, day and night ; 
for a mild case, every hour by day and every two hours by night; 
administer always ice-cold. 



CEREBROSPINAL MENINGITIS. 301 



CEREBRO-SPINAL MENINGITIS. 



Cerebrospinal meningitis (epidemic as distinct from simple and 
tubercular meningitis, )j.r/yiy^, a membrane). — An acute infection, 
caused probably by various bacteria, commonly by a diplococcus, 
characterized by sudden onset, headache, opisthotonos, herpes, 
hyperesthesia, and constipation. 

History, Geography, etc. — Cerebro-spinal meningitis is a dis- 
ease of modern origin or of modern recognition, for previous to the 
present century there was no possible differentiation of this disease 
and forms of typhus fever, pernicious malarial fever, tetanus, and 
the various inflammations of the brain and cord, diseases known to 
be as old as the history of medicine. 

It is now conceded that it was first remarked as a separate dis- 
ease in Geneva, February, 1805, by Vieusseux, who called the mal- 
ady a fievre cerebrate ataxique, and admitted that neither he nor 
his colleagues had ever seen a similar disease. 

The next outbreak of the disease, with unmistakable signs, oc- 
curred in our own country, with the first cases at Medfield, Mass., 
in 1806. These cases formed the preface to a long chapter in the 
history of the disease, known then as " sinking typhus," ten years 
in duration, during which time it extended over, but remained con- 
fined to, the New England States. 

Though doubtful cases prevailed before this time, cerebro-spinal 
meningitis belongs to the nineteenth century, and its history natu- 
rally falls into three periods, quite distinct, the first embracing the 
first cases of " ataxic cerebral fever," observed at Geneva in 1805, 
and of " spotted fever," in Massachusetts, in 1806 ; the second com- 
mencing with the outbreak at Bayonne in 1837, and extending over 
various parts of Europe and America up to the year 1866, gradu- 
ally merging into the third or present period, when the disease has 
become nearly universal. 

Cerebro-spinal meningitis belongs among the rarest of epidemic 
diseases. Since the establishment of the disease as a pandemic af- 
fection sporadic cases are of continual recurrence, but these cases re- 
main isolated as a rule. The practitioner is often surprised at being 
confronted with a pronounced case of this disease in a crowded ten- 
ement house, in a palatial suburban residence, in a barrack or jail, 
in the ward of a hospital, in a distant farmhouse, when no similar 
case may have been reported, and probably no other case may show 
itself for years. Widespread epidemics constitute the great excep- 
tion in the history of this disease, the outbreak at Dantzic in 1864- 
65 being the only notable example. So that individual cases, not 
distinctly marked, are apt to be overlooked for a time or erroneously 



302 CEREBROSPINAL MENINGITIS. 

diagnosticated, and numerous instances are recorded in which the 
diagnosis has "been fully established only upon autopsy. 

Etiology. — Every attempt to connect cerebro-spinal meningitis 
with any special climate has turned out a signal failure. Equally 
futile has been the endeavor to fix the disease in connection with any 
special soil. But the season of the year has more to do with the 
development of this disease. Perhaps the most striking fact appa- 
rent in the study of the etiology of this affection is the frequency 
of its occurrence during the colder months of the year. Thus, of 
fifty-two epidemics in France and Switzerland, twenty-three occurred 
in winter, thirteen in winter and spring, and but two in the midst 
of summer ; while of sixteen epidemics in our own country, six oc- 
curred in winter and five in winter and spring. 

While it is acknowledged of cerebro-spinal meningitis that an 
almost freakish variation has occurred in its attack of individuals, it 
is generally conceded that it shows predilection . for the period of 
youth- Thus it is stated by Hirsch that of 1,267 fatal cases in 
Sweden in the years 1855-60, where the age was stated, 889 were 
under fifteen years of age, 328 from sixteen to forty years, and 50 
over forty years of age. Emminghaus makes the collective state- 
ment, from over fifty extensive observers, that of 1,435 cases 1,133 
were under fifteen years of age. Smith, New York, found that of 
975 cases 771 occurred in persons under fifteen years of age, and 336 
in children under five years of age. In some epidemics children 
have been the only victims of the disease. 

Individual epidemics have been frequently noticed to have been 
distinctly connected with different social states. The selection of 
soldiers as exclusive victims has made this disease a familiar guest 
in army life. The recent conscripts and new recruits have been 
often the sole victims of the disease. Pfeiffer says the disease " pre- 
fers winter, soldiers, and children." 

A strict localization of the disease to certain houses, flats, or sto- 
ries has often been observed/ Prisons, workhouses, orphan asylums, 
constitute at times breeding places of cerebro-spinal meningitis. The 
epidemic in Ireland in 1846 was strictly confined to the prisons, and 
the disease broke out with the same seclusion in the orphan asylums 
in Philadelphia and Vienna in 1863, Washington in 1869, and Jeru- 
salem in 1872. 

One attack of cerebro-spinal meningitis confers future immunity. 

Symptoms. — The disease begins with the aspect of a grave, acute 
infection. As a rule the onset is sudden, with the impress of pro- 
found toxaemia. A chill comes on in the midst of apparent health, 
with vomiting, excruciating headache, and rapid prostration. 
Tenderness and stiffness in the back of the neck supervene in the 



CEREBROSPINAL MENINGITIS. 



303 



course of a few hours. The face is pale, the expression anxious and 
strange, the extremities stiff and tremulous. The slightest motion 
intensifies the pain in the whole body ; the act of vomiting makes it 
atrocious. A sense of formication with hyperesthesia is felt first, 
as a rule, in the lower extremities, to which it may remain confined, 
or it may extend over the whole body. The special senses of sight 
and hearing become likewise supersensitive. A flare of light, the 
slam of a door, the rumble of wheels in the street, a touch of the 
bed, produce a condition of agony. Even the approach of an at- 
tendant with the gentlest ministrations is watched with apprehen- 
sion. Temporary relief of this distress is secured during a state of 
sopor or stupor which may occur, from which the patient awakens 
or is aroused — children often with a cri hydrocephalique — with a 
renewal of the same symptoms in greater or less degree. 

In the course of a few days, often during the same day of attack, 




Fig. 165.— Extreme opisthotonos. From the original painting by Sir Charles Bell (Spence). 



the stiffness of the neck increases to rigidhw, or extends to constitute 
the characteristic opisthotonos. 

Opisthotonos stands in the foreground in the semeiology of this 
disease. It is rare that some degree of rigidity in the back of the 
neck is not present, though Burdon Sanderson declares that in the 
Prussian epidemic, 1864-65, there were many cases in which there 
was no stiffness or retraction of the muscles. In the lightest cases 
there is simply a sense of increased resistance on attempts at flexion 
of the head upon the chest — a valuable point in differential diagnosis 
— or a slight degree of tenderness to pressure upon the cervical ver- 
tebrae. In most severe cases rigidity is marked, with retraction of 
the entire head, to such degree at times as to give rise to extreme 
mechanical dysphagia. Leyden speaks of cases in which the head 
was bent back at a right angle to the spine, and Gordon mentions an 
instance in which, in addition to this deformity, the spine presented 



304 CEREBROSPINAL MENINGITIS. 

" a most wonderful uniform curve concave backward." The most 
striking illustration of the degree to which this extension may occur 
was reported by Neville Hart in a case in which the pressure of the 
occiput caused a slough between the scapulae. In the experience of 
this author the degree of opisthotonos corresponded with the gravity 
of the disease. Not infrequently the rigidity extends lower in the 
vertebral column, as in Gordon's case just mentioned. Thus Jan- 
sen mentions an instance where the whole body could be lifted rigid 
with the hand behind the occiput, and Ziemssen and Merkel report 
cases of ' ' orthotonos " in which attempts to flex the head pushed 
the body like a statue to the foot of the bed. With the other symp- 
toms mentioned this condition may disappear, to reappear in greater 
or less degree, undergo fluctuations throughout the disease, con- 
tinue to the fatal end — as long in one case as forty -nine days — or re- 
main in some degree until full recovery. Ziemssen speaks of conva- 
lescents going about with rigid spines, and cases are reported in 
which the condition lasted throughout life. Usually the retraction 
is symmetrical, as pleurosthotonos is very rare. The rigidity is due 
to tonic contraction of the deep muscles of the neck, the splenii ; the 
superficial muscles, the trapezii, remain unaffected. Convulsive 
twitchings of the face, or clonic spasms in the muscles of the ex- 
tremities, may now occur, with delirium or outbursts of maniacal 
excitement under the slightest provocation. In the case of a young 
lady, under the observation of the author, clonic convulsions of the 
upper extremities existed continuously for three days and nights, and 
were only stilled finally by narcotic doses of opium. This patient 
escaped with life, but with lesions that left it of little value. 

The skin shows the greatest variety of eruption of any one of 
the acute infections, with nothing peculiar or pathognomonic in any. 
A scarlatinous blush, more especially of the face, is very frequent in 
the first days of the disease^ and a roseolar exanthem, more espe- 
cially upon the trunk and extremities, frequently follows later. 
Hirsch speaks of spots resembling measles, Ziemssen mentions urti- 
caria, Kamph erysipelatous macula?, Grimshaw pemphigus, and 
Jenks bullae, in individual cases. As to the petechia? which have 
falsely named the disease, they are most frequently distinguished by 
their absence. Yet bloody eruptions or extravasations do occur in 
this disease as frequently as in any acute infectious malady of equal 
gravity. 

The only eruption which has any real significance in meningitis 
is herpes. It begins usually as early as the third day of the disease, 
and may continue in renewed eruption throughout its course, or, as 
Hirsch remarks, weeks after full recovery. It shows itself first, as a 
rule, about the face, on the lips, nose, forehead, and neck, or may 



CEREBROSPINAL MENINGITIS. 305 

extend to the chest, abdomen, back, nates, and even the extremities. 
Pneumonia is, perhaps, the only disease which shows herpes in equal 
frequency, but the herpes of meningitis differs from that of pneumo- 
nia in having no prognostic value. In fact, a renewed outbreak 
rather signifies an exacerbation of the disease. 

The temperature curve of the disease distinguishes itself by its 
irregularity. As a rule it rises quickly at first to 102° F., or even 
104° F., to fall in the course of a few days, or to undergo fluctua- 
tions in extreme degree, sinking at times below the normal. An ex- 
treme hyperpyrexia not infrequently precedes a fatal termination, 
which is usually attended, however, with a reduction to correspond 
with the marble coldness of the skin. 

The pulse increases out of all proportion to the temperature, to 
experience, later on in the attack, greater fluctuation in frequency, 
volume, and tone than in almost any other disease. The same va- 
riations are noticed also hi the acts of respiration, which are often 
quick and slow in the course of the same hour of the day. 

The tongue is usually dry and red, in bad cases fissured and fu- 
liginous, and sordes in these cases cover the teeth and gums. 

The abdomen is sunken and retracted, often to such a degree as 
to show the outlines of the bodies of the vertebrae, or make distinctly 
apparent the crests and prominences of the iliac bones. Constipa- 
tion is present, as a rule. The urine flows scantily and slowly from 
a paretic bladder, or in the worst cases is voided unconsciously in 
bed. Trismus, singultus, delirium, and coma, with ecchymoses and 
meteorism of the abdomen, mark the speedy advent of the close of 
the disease ; or relaxation of the opisthotonos, relief of the pain in 
the head, with critical sweats or enuresis, indicate a favorable reso- 
lution. 

Of the symptoms produced by the local lesions, pain in the head 
is among the most prominent. Headache — crushing as if produced 
by a vise, or boring as from the penetration of nails or screws — is, as 
has been stated, one of the initial signs, and it constitutes always one 
of the most obstinate and distressing features of the disease. Fortu- 
nately it is subject to intermissions or remissions in the course of the 
disease, and not infrequently it disappears altogether. The other 
signs of the disease may then still remain in force, though cessation 
of headache may be usually regarded as one of the most favorable 
signs in prognosis. Warning should be entered here, however, 
against that ominous arrest of headache, along with a general 
euphora, which sometimes immediately precedes the end. Vertigo 
may be associated with the headache, to greatly aggravate the suf- 
ferings of the patient by compelling the continued observance of the 
recumbent posture. 
20 



306 CEREBROSPINAL MENINGITIS. 

Pain of a similar character, indescribable in its intensity, is also 
felt in other parts of the body, in the spinal column — rhaclnalgia — in 
the extremities, or anywhere upon the surface in the course of the 
spinal nerves. Usually such pain is paroxysmal, fulgurant, agoniz- 
ing'. It shoots out from the posterior nerve roots of the spinal cord, 
where the local lesion, as determined by gravity, is most intense, and 
carries with it sickening sensations of precordial depression. 

A more characteristic, though less frequent, sign of cerebro-spinal 
meningitis is hyperesthesia of the surface. It is commonly absent 
altogether in the lighter or abortive forms, and may not show itself 
throughout the short course of the foudroyant forms, but it is quite 
constant, at least in the earlier days of the disease, in cases of average 
intensity. It is first seen, as a rule, in the lower extremities, to which 
it may remain confined, next in the upper extremities, and lastly in 
the face and head. Like the pain, it may undergo remissions and 
exacerbations, may disappear to recur later, or may last over, in 
regions, to the period of convalescence. When present it adds a 
peculiar poignancy to the suffering of the patient, who watches with 
anxious eyes every movement about the room. In aggravated cases 
it is manifest also during sleep, and even the stupor of coma does not 
entirely annul it. In such cases it interferes with, or even entirely 
prevents, an examination of the patient, which, however, may be un- 
necessary, as, with the history and superficial inspection, it frequently 
declares the disease. It is often absent throughout the whole course 
of the malady. 

The symptoms on the part of the digestive system belong among 
the cardinal manifestations of the disease, as vomiting ranks in signi- 
ficance along with the chill, headache, and opisthotonos. It is only 
the mildest cases which show no disturbance of the stomach. It 
ceases frequently in a few days, to reappear in bad cases, and to re- 
main at times a more or less constant attendant of the disease. 

Complications. — Cerebro-spinal meningitis is particularly prone 
to a number of grave complications and sequelae, prominent among 
which may be mentioned paralysis and paresis of various organs 
and members, and profound, often permanent lesions of the eye and 
ear. 

Among the most frequent and serious of the complications are 
catarrhal and croupous pneumonia. Of these affections catarrhal 
pneumonia, or broncho-pneumonia, is most frequently encountered in 
children, and, if developed as a secondary affection, readily under- 
goes favorable resolution. But croupous pneumonia has a much 
more serious prognosis. It occurs more frequently in certain epi- 
demics — fifteen times in the Erlangen epidemic of 1866 to 1872 — and 
develops by predilection in the later periods of the outbreak of the dis- 



CEREBROSPINAL MENINGITIS. 307 

ease. Hyperesthesia may eventuate in anaesthesia to such degree 
as to permit the penetration of a pin. 

Of the special senses, besides that of touch, the senses of vision 
and hearing suffer most. Corresponding to the hyperesthesia or hy- 
peralgesia of the surface of the body is photophobia, to such degree, 
as a rule, as to necessitate the darkening of the chamber and the 
avoidance of artificial light. Graver lesions than this functional dis- 
turbance, conjunctivitis, iritis, irido-choroiditis, neuritis, atrophy of 
the optic nerve, even panophthalmitis, may occur in the course of the 
disease. The same exaltation of sensibility affects the ear with even 
greater distress, because offence in this regard is less preventable. 
Suppurative processes in the middle and internal ear, perforation of 
the membranes, atrophic changes, are among the graver affections 
of this organ as complications and sequelae of this disease. So cere- 
brospinal meningitis is one of the most common causes of deafness, 
perhaps the most common cause of all diseases affecting the internal 
ear. For in the vast majority of cases the affection is bilateral and 
permanent. Deaf -mutism most frequently results from this disease. 

Forms. — Although different epidemics exhibit great variations in 
the degree and number of the symptoms cited, cerebro-spinal men- 
ingitis usually shows itself besides, in the typical cases mentioned, 
in one of three distinct forms or types — namely, the abortive, the in- 
termittent, and the siderant or foudroyant. 

The abort iveiorm. exhibits all its symptoms in the lightest grade. 
The headache is slight, the stiffness of the neck trivial or temporary, 
and vomiting may not occur, or may not recur after the first attack. 
Such cases often entirely escape recognition, or are diagnosticated 
only because of the prevalence of an epidemic of the disease. 

The intermittent form is noticed more especially in certain epi- 
demics, though such cases are wont to occur in any extensive out- 
break of the disease. Not infrequently isolated sporadic cases 
assume this form, to the great embarrassment of the practitioner. 
Quotidian and tertian intermissions or remissions occur in all the 
symptoms of the disease, leading often for a time to erroneous prog- 
nostications. The intermissions are by no means as distinct, as a 
rule, as the periodicities of malarial disease, yet they prove exceed- 
ingly deceptive to superficial observation. The exacerbations corre- 
spond undoubtedly to the irregular invasions or advances of the 
cause of the disease. 

The foudroyant is the fulminant form, in which the patient is 
often killed by the force of the poison before permanent local lesions 
liave time to develop. These are the cases which destroy life in the 
course of from six to thirty-six hours. The patients in these cases 
are often suddenly stricken with unconsciousness and convulsions, 



308 CEREBROSPINAL MENINGITIS. 

sometimes preceded for an hour or two with vomiting and pain in 
the head, in which condition they are carried home, pallid, cold, or 
slightly cyanotic, showing no reaction to the most powerful stimu- 
lants, to sink into coma and speedily succumb. 

Morbid Anatomy. — The external appearance of the body in 
cerebro-spinal meningitis varies with the duration of the disease. 
Rapid or foudroyant cases exhibit no change, but cases of longer 
duration show an emaciation which in protracted illness simulates 
that of cancer and tuberculosis. No trace of eruption is discover- 
able, as a rule, though occasionally the surface remains covered with 
petechise. Suggillations form quickly and in quantity over the body, 
and post-mortem rigidity sets in soon. Moreover, decomposition 
begins unusually early in rapid cases, as in other acute infections. 
In the most chronic forms, with extreme emaciation, bed sores are 
common and extensive. 

The muscular tissue is in the foudroyant cases brown and fragile, 
in cases of average duration more pale from loss of blood. The 
molecular change of fatty degeneration invades its structure, and 
gives it the appearance, which is especially remarked of the heart, of 
being strewn with sand. 

The condition of the spleen varies greatly. It is usually found 
swollen in fulminant forms, with deeply darkened pulp, but not in- 
frequently it is shrunk to such degree as to show a wrinkled cap- 
sule. In average cases it is rather the rule to find this organ of 
diminished size. As might have been expected, the intermittent 
forms show no enlargement of the spleen. The cloudy swelling, 
fatty and granular degeneration of the kidney and liver, ecchymotic 
state of the mucosae, oedema of the lungs, effusions in the serous 
sacs, post-mortem softening of the stomach, swollen condition of the 
mesenteric glands, dark color and altered consistence of the blood, 
are changes which belong to all the acute infections and are espe- 
cially marked in this disease. , 

The characteristic lesions are encountered at the anatomical seat 
of the disease, in the membranes of the brain and cord. 

On opening the skull the membranes of the brain are revealed in 
a state of intense hypersemia. The sinus longitudinalis is distended 
to tension of its walls, and ail visible vessels are filled to their utmost 
capacity. In fulminant cases there may be no trace of exudation,, 
but the pia mater is already opaque and lustreless, sometimes ecchy- 
motic, from infiltration into its texture. The substance of the brain 
and cord is cedematous and softened in the most superficial layers. 

In cases of longer duration the dura mater is stretched tense by 
the effusion beneath it, punctate haemorrhages are diffused over its 
surface, and the hypersemia involves the porous substance of the 



CEREBROSPINAL MENINGITIS. 309 

bones of the spinal column, whose spongy structure appears saturated 
with blood. The pia mater is reddened with distended vessels, is 
opaque in some places, ecchymotic in others, and is softened in spots 
or more extensive surfaces. The first exudation is a light serum, 
which soon becomes an opaque milky fluid of semi-gelatinous or 
mucilaginous consistence, sticky, "drawing to a thread," which later 
becomes greenish, " leek-green," or yellowish with pus. It is effused 
first in the subarachnoid spaces and along the course of the vessels of 
the pia mater at the base and sides of the cerebrum, in the fissure of 
S}dvius and between the cerebrum and cerebellum, or extends over the 
whole surface of the brain to form a veritable cap. Or the exudation, 
more limited to the base, surrounds the emerging nerves, dissecting up 
their investing sheaths and following them out in their course. In 
the spinal column the exudation is deposited first along the posterior 
aspect of the cord, as determined by gravity, but soon extends to its 
lateral surface to affect or to follow out the spinal nerves in the 
same manner as in the brain. The thickest masses of exudation are 
found in the cervical and lumbar regions of the cord, though effusion 
in spots, bands, or islands occurs irregularly throughout its course. 
In its advance the suppurative process invades the sheath of the 
optic nerve, to travel along its course, infiltrate the orbital fat, to 
account in life for an iritis, choroiditis, or an all-destructive panoph- 
thalmitis. So, also, implication of and transit along the facial and 
auditory nerves lead to destructive changes in the ear. 

A microscopic examination reveals the fact that the inflammation 
affects the tissues through the blood vessels. Numberless round 
cells infiltrate the intima and adventitia, to collect on the external 
surface and form the lines and layers of pus cells along their course. 

Duration. — Cerebro- spinal meningitis has no definite duration. 
Hirsch says of it that it may last from a few hours to several months. 
The first period applies to the foudroyant cases, in which patients are 
killed as by a stroke; the last to the cases with complications or 
sequelae, which may, indeed, prolong the disease indefinitely. Gor- 
don's shortest case was five hours, and Jewell records a case of death 
in three hours and a half after seizure. These are, of course, most 
extreme and exceptional cases. Clymer states that more than one- 
half the deaths happen as early as from the second to the fifth day. 
This author quotes also from Parkes, who found the duration of the 
disease in sixty-six of ninety-five cases, five days or less; in one, eight 
days; in twenty-eight, eight days or over. Abortive forms termi- 
nate in resolution in from three to five days; foudroyant forms, with 
rare exceptions, in death within three days; and intermittent and 
average forms in one or the other way, barring complications and 
sequelse, in from one to three weeks. 



310 CEREBROSPINAL MENINGITIS. 

Diagnosis. — In the presence of an epidemic of the disease the 
diagnosis of cerebro-spinal meningitis is sufficiently easy. The exist- 
ence of cases in the vicinity prepares the practitioner for new attacks. 
Cases which are affected with, or more especially quickly succumb 
to, any disease with predominant nervous symptoms should excite 
the suspicion of the physician in this direction. Sporadic cases, how- 
ever isolated in space or time, are likewise readily recognized in the 
presence, in sufficient number, of the symptoms peculiar to the dis- 
ease. The sudden seizure, often in the midst of health, with chill, 
vomiting, and prostration, followed by opisthotonos, hyperesthesia, 
herpes, irregular pulse, constipation, constitute an array of symptoms 
that belong to no other disease. Unfortunately for the diagnosis, 
many cases deviate from the regular type in essential particulars, 
more especially in the absence of characteristic signs, to such degree 
as to make the diagnosis difficult or at times impossible. Foudroyant 
cases differ most widely by the predominance of the symptoms of 
blood poisoning which are common to all the grave acute affections. 
Light is sometimes thrown upon these cases by the consideration of 
the season of the year, the age of the patient, the existence of other 
cases more pronounced, or, if equally obscure, by the exclusion of 
simulating maladies or accidents. Thus a meningitis from trauma, 
syphilis, or otitis should be discovered by the history and inspection 
of a case ; or occurring in the course of scarlatina, pneumonia, sep- 
ticaemia, it should be eliminated by the presence of signs character- 
istic of these affections. 

Typhoid fever distinguishes itself by the fact that it usually spares 
the period of earliest youth, that its onset is insidious, that it is at- 
tended with diarrhoea and distention of the abdomen, that it often 
shows a rose-color eruption, has a constant high pulse, a typical tem- 
perature curve, and a definite duration. Moreover, typhoid fever 
almost never shows herpes, and almost always shows enlargement of 
the spleen. Malarial fever is marked by its preference for certain 
regions and certain seasons of the year. Periodicity is the criterion 
of malaria, and, though this factor is simulated in the intermittent 
cases of meningitis, it is never so precise. Reeve says the early vom- 
iting was the key to the diagnosis of his first cases of meningitis. 
Whatever doubt may exist at first is quickly dissipated by the admin- 
istration of quinine in sufficient dose. Tetanus is eliminated by its 
trismus, and hydrophobia by its characteristic paroxysms of inspira- 
tory spasm. Tubercular meningitis rarely shows symptoms on the 
part of the spinal cord, though opisthotonos and hyperesthesia are 
not uncommon in this disease. Tubercular meningitis is nearly con- 
fined to childhood. In the great majority of cases its victims are of 
tuberculous parentage or stock. It is not affected by the season of 



CEREBROSPINAL MENINGITIS. 311 

the year. It distinguishes itself especially by its long prodromal 
stage, by its periods of reduction of temperature and retardation of 
pulse, by the occasional signs of tuberculosis elsewhere, in the lungs 
or intestines, externally (scrofula) upon the skin, or possibly in the 
bottom of the eye. 

Prognosis and Mortality. — The prognosis of this disease is al- 
ways grave. The factor of most importance in its determination is 
the type of the disease. Foudroyant cases perish with very rare 
exceptions, abortive forms recover with but few exceptions, and 
average cases survive and succumb in about equal number. The 
character of the epidemic is the next consideration. Certain out- 
breaks are distinguished by their mildness, as are others by malig- 
nancy. Between these extremes is every grade of gravity in different 
attacks. It is also true of this, as of most of the acute affections, that 
the first cases are most severe. The epidemic grows feebler, as a 
rule, with the gradual exhaustion of its most fertile soil. Individual 
considerations follow next. The prognosis is more grave in infancy 
and childhood than in adolescence and maturity. The ratio of mor- 
tality falls from 75 per cent in children under one year of age to 53.5 
per cent in later childhood and 35 per cent in adolescence. Of 15,632 
cases analyzed by Hirsch, 5,731 terminated fatally. Thus the ave- 
rage ratio of mortality of this disease, under all conditions, is given at 
37 per cent. The influence of "bad hygiene" in aggravating the 
prognosis is too patent to require mention. Of more importance are 
the signs which prognosticate the result in individual cases. It may 
be stated as a rule of this, as of all the acute infections, that a severe 
onset indicates a grave case. Thus a high fever at the start, obsti- 
nate vomiting, marked opisthotonos, early convulsions, are signs of 
ominous import. As one-half the deaths happen before the fifth day 
(Clymer), a case which survives the first week has a more favorable 
outlook. The first three or four days are attended with the greatest 
anxiet} T . " Every day passed after, the seventh day renders recovery 
more and more probable" (Loomis). Typhoid symptoms at any 
stage of the disease imprint upon it an unfavorable prognosis. Arch- 
ing of the great fontanelle, as indicative of intracranial oedema and 
exudation, is a very bad sign. Almost all such cases end fatally 
(Maurer). A return of headache and vertigo which has disappeared, 
especially if associated with vomiting and convulsions, evidences of 
consecutive hydrocephalus, is likewise ominous (Ziemssen). Yet 
secondary hydrocephalus is not absolutely hopeless, as Ziemssen saw 
" some cases in which a complete, and others in which an incomplete, 
recovery took place." Profuse sweats, with cold surface, are charac- 
teristic of a fatal issue (Hirsch). The persistence, after recovery 
from the disease, of anorexia, debility, and emaciation, perhaps with 



312 CEREBROSPINAL -MENINGITIS. 

diarrhoea, gives a poor outlook, especially for children (Emminghaus). 
A sudden high elevation of temperature, or hyperpyrexia, after a chill 
in a previously apyretic case, means a complication and not a fatal 
issue; but a hyperpyrexia without chill, and with a profuse sweat, is 
pre-agonic (Immermann). 

Treatment. — A patient affected with this disease should lie upon 
a comfortable bed, not too hot, in a spacious, continuously ventilated 
room, whose windows can be darkened, if necessary, while they 
still admit the air, as remote from the street with its offensive 
sounds as may be. The temperature of the room should be regu- 
lated, with a thermometer near the head of the bed, at 65° F., by an 
open fire, preferably in a grate. The physician and the necessary at- 
tendants should be the sole visitors. Quiet should reign supreme. 
In no other disease is continuous or officious ministration so meddle- 
some and mischievous. Even cleanliness or apparent discomfort in 
posture must be sacrificed at times to peace of mind. The diet is to 
be simple and light at first, but as nutritious as possible with return- 
ing health. Beef tea palatably made, soups of any kind, milk if it 
do not increase constipation, scraped raw meat with a little salt, 
gruels if not distasteful, with water, Selters water, Apollinaris, an}^ 
simple carbonated drink, should be proffered at proper intervals, 
without over-solicitation or any anxiety should everything be re- 
fused. With the beginning subsidence of the disease an egg may be 
dropped into the soup, or sweetbreads, fish, the white meat of fowl, 
may for a few days preface the more solid meats. 

Especial attention is to be paid to the bladder. The soft catheter, 
thoroughly cleansed, warmed above the heat of the body and 
greased with pure vaseline, brings this organ, when refractory, un- 
der control. Constipation is overcome with calomel, two to ten 
grains, or castor oil, in preference to an enema, which causes too 
much disturbance. 

The treatment proper is purely symptomatic and has reference to 
both sets of symptoms, general and local. Of these the symptoms 
produced by the local lesions — pain, opisthotonos, hypersesthesia — 
assume prominence in the great majority of cases. For the relief 
of these symptoms no remedy equals in value opium. Opium is the 
"sheet anchor "in the treatment of cerebro-spinal meningitis. It 
acts solely by its anodyne influence. It protects, by obtunding, the 
nervous system until the force of the poison is spent. Surprising 
amounts of the drug may be given in this disease without narcotic 
effects. Thus Steiner often gave ten grains at a dose in cases of se- 
vere convulsions, without producing stupor ; Chauffard, three to fif- 
teen grains ; and Boudin, seven to fifteen grains at first, and later 
one to two grains every hour, before soporific effects were produced. 



RHEUMATISM. 313 

Stille was in the habit of prescribing one grain every hour in very 
severe, and every two hours in moderately severe, cases, without in- 
ducing even an approach to narcotism in any case. ■ i Under the in- 
fluence of the medicine the pain and spasms subsided, the skin grew 
warmer and the pulse fuller, and the entire condition of the patient 
more hopeful." When quick effects are to be had, or when the drug 
is rejected by the stomach, resort will be had, of course, to the hy- 
podermatic use of morphia. Ziemssen gives expression to an expe- 
rience made by every practitioner with this disease when he says 
that morphia is, without doubt, " indispensable " in its treatment. 

Cold, in the form of bags of ice to the head or along the spine, is 
of great value when the period of excitability, hyperesthesia, and 
jactitation may have given place to the state of sopor and indiffer- 
ence. Radcliffe claims that " the application of cold to the head 
and spine, either by means of ice or a freezing mixture in Esmarch/s 
(or Chapman's) india-rubber bags, has furnished by far the most sat- 
isfactory results of all direct treatment." 

Vomiting is best relieved by ice, champagne, effervescent drinks, 
milk and lime water, bismuth, soda, creosote, and chloral. No drug 
^equals in efficacy, at times, sips of water excessively hot. 

Hiccough is often brought under control by the same means pre- 
scribed for vomiting, by the administration of a few drops of the 
oil of cajuput, or by clysters of sodium bromide or chloral. More 
obstinate cases of either vomiting or singultus call for the subcuta- 
neous use of morphine. 

RHEUMATISM. 

Rheumatism (pev/ua, peso, to flow), with the same derivation as 
catarrh ; from the old Greek idea of a peccant humor circulating in 
the blood and instilled into the joints. — A term applied subsequently 
to all kinds of maladies thought to be due to exposure to cold, limited 
about the time of Ballonius (1600) to pains about the bones, joints, 
and other structures than mucous membranes, to which alone the 
term catarrh was confined. In our day catarrh is further limited to 
express those inflammations of mucous membranes which are not to 
be attributed to any special or specific cause, while rheumatism has 
yet much of the vague and diffuse meaning of ancient times. Thus 
the older writers spoke of visceral, gastric, cerebral, cardiac, vesi- 
cal, etc., rheumatism ; certain modern writers continue to describe 
cases of rheumatic pleurisy, peritonitis, etc., and the oculists still 
speak of rheumatic iritis in describing affections which are not to be 
attributed to a specific cause. 

Pathology. — Rheumatism is, therefore, still a sort of refuge for 
maladies, especially affecting the bones or joints, whose real nature 



314 RHEUMATISM. 

is unknown. Sydenham separated gout, Senator arthritis, Zenker 
trichinosis. ~No less than five maladies are still considered under the 
head of rheumatism, but definite ideas cannot be had concerning any 
of them until each is distinctly isolated, if not as to its cause, at least 
as to its symptomatology. There is thus, first, acute articular rheu- 
matism ; second, chronic articular rheumatism ; third, muscular 
rheumatism ; fourth, gonorrhceal rheumatism ; fifth, nodular rheu- 
matism. These various affections must be separated from each 
other and from gout, syphilis, tuberculosis, rickets, or other affec- 
tions of the bones and joints, before any clear understanding may 
be had of any one. It is probable that in the near future the term 
rheumatism will be confined to that acute articular variety which 
distinguishes itself by a more or less sudden onset with fever after 
the manner of an infection, inflammation of a number of joints with 
sweating, and liability to affection of the heart. This disease is 
commonly known as inflammatory rheumatism because of the 
acuteness and intensity of the inflammatory signs. The other dis- 
eases, until better defined, may be known as rheumatoid affections 
of the muscles, bones, or joints. 

Acute Rheumatism occurs at all seasons of the year, but with 
preference for the fall and winter months, and thus more espe- 
cially in connection with changing temperatures. It attacks par- 
ticularly or almost exclusively the period of adolescence, from fifteen 
to thirty or thirty-five. Acute rheumatism in infancy or early 
childhood is almost unknown. Individuals with the widest oppor- 
tunity for observation record isolated cases of rheumatism in the 
earlier weeks of life. Liability begins at four, begins to cease at 
forty, and is almost nil at fifty. Cases at or over fifty are survivals 
from earlier periods. It seizes by preference the poorer or working 
class, that most exposed to changes of weather, but picks espe- 
cially upon certain individuals who seem to possess for it a natural 
predisposition. What constitutes this susceptibility is unknown. 
These individuals suffer, not one, but repeated attacks, for rheuma- 
tism is a disease to which the individual, originally so to some extent, 
becomes more susceptible after each attack. 

Rheumatism is commonly ascribed to taking cold, though there 
is no more satisfactory explanation of the relation between cause and 
effect in this than in any other disease said to be due to the same 
cause. The older writers spoke of rheumatism as a neurosis. Im- 
pressions made upon the skirl were conveyed through the nerves to 
be reflected to the joints. The impression of cold was said to seize 
upon the joint as a locus minor is resistentice — an explanation which 
is only a paraphrase. 

Froriep and Canstatt invoked a toxic theory in ascribing rheuma- 



RHEUMATISM. 315 

tism to the accumulation or to the excess of lactic acid in the blood, 
and some support seemed to be lent to this view through the fact 
that the administration of lactic acid in large doses, as in the treat- 
ment of diabetes, produced in some cases inflammation of the joints. 
This view, however, lacks the important support of the discovery or 
detection of any excess of lactic acid in the blood. The tendency in 
our day is to regard rheumatism as an infection or mycosis, based 
upon the facts (1) of the nature of its onset and course ; (2) of the 
occurrence of the disease undeniably in the course of certain infec- 
tions, as scarlet fever, dysentery, puerperal fever ; (3) that the 
remedy which has over it almost specific control— salicylic acid — is a 
powerful antimycotic remedy. But this view lacks also the all-im- 
portant evidence, or at least sufficient evidence, of the discovery 
of any particular micro-organism in the blood or organs affected by 
the disease. Buday (1892) found that the injection of the Strepto- 
coccus pyogenes into the jugular vein of the rabbit was followed by 
inflammation of the joints! In six fatal cases of acute rheumatism 
in man pyogenic micro-organisms were found in the joints, as they 
are in the fluid of all cases examined. They are discharged into the 
joint by the rupture of metastatic (capillary) emboli. 

Symptoms. — Rheumatism begins with a chill, or series of shiver- 
ing fits, attended and followed by rise of temperature to 102°-105° 
F., in the course of the first twelve to twenty-four hours. There is 
at this time the malaise and distress which belong to fever, though 
there is not, as a rule, the same anorexia, nausea, or nervous dis- 
turbance that belong to most of the acute infections. Rheumatism, 
in fact, distinguishes itself rather by the absence of these signs in its 
inception. The nature of the disease is proclaimed in the course of 
the first twelve to twenty-four hours by the affection of the joints. 
The rule is that the medium-sized joints are affected first : thus the 
knee and the ankle and the wrist, and afterward the shoulder and 
elbow, then, some time after, in the order of frequency, the fingers 
and the joints of the vertebrse. 

In bad cases unusual joints are affected, as the joints of the jaw, 
of the larynx, of the symphyses, of the ribs, so that in an extreme 
case the patient lies paralyzed as to motion, on account of pain, which 
is perceived all the more acutely because of the clearness of the sen- 
sorium. The affection of the joints announces itself also by the in- 
hibition of motion. The limbs are held in the semi-flexed position 
to avoid tension, and as absolutely immobile as may be. Every agi- 
tation of the room, more especially of the bed, increases the pain, 
which shoots through the joints like the stab of a knife and dies 
away only gradually under perfect rest. 

The medium-sized and smaller joints show inflammation by 



316 RHEUMATISM. 

swelling or redness as the synovial fluid is increased to cause disten- 
tion of the capsule of the joint. Sometimes the skin over the joint 
pits upon pressure from a subcutaneous oedema. Spots or strips of 
redness are to be seen over the larger joints. Sometimes a sheet of 
crimson red announces the intensity of the inflammation beneath. 
In cases of the largest joints, as the hip or the shoulder, there may 
be no external discoloration, on account of the depth of the disease. 

What especially characterizes this form of rheumatism is the 
fugacity of the affection. It attacks a joint severely, so that it 
remains inflamed intensely for a few days, whereupon it disappears 
to attack another joint or joints. Rheumatism is said to fly from 
joint to joint. Sometimes it returns to the joint first affected, and 
thus projects itself over a long period of time. But, notwithstand- 
ing the intensity of the inflammation, as manifested by the swelling, 
redness, and pain, the disease disappears when it subsides, to leave 
no trace. There is in rheumatism a restitutio ad integrum. 
Should suppuration occur, or should the joint be left anchylosed, it 
is a case of mixed infection. Pure rheumatism shows no pus and 
leaves no deformity in the joints. 

A prominent symptom in the course of rheumatism is sweating, 
which is ordinarily so profuse as to saturate the garments and the 
bed linen. The perspiration has an acid reaction and an intensely 
sour odor. But the evaporation of this large amount of fluid has 
little or no effect upon the temperature. Where ablutions are not 
frequently practised sudamina form, and may be seen as glistening 
vesicles, sometimes over the whole surface of the body. 

The grave complication of rheumatism occurs in the heart. In 
a certain percentage of cases either pericarditis, endocarditis, or 
myocarditis occurs in the course of rheumatism. This complication 
does not occur always in correspondence with the severity of the 
fever or the number of joints affected ; involvement of joints near 
the heart has nothing to do with its production. Thus an affection 
of the foot would be as likely to be attended by heart disease as an 
affection of the costo-chondral joints. The heart is affected more 
especially in the young. The patient between fifteen and twenty- 
five is most liable to suffer heart complication. Attacks in later life 
are generally free from heart disease. 

Authorities differ as to the frequency of this complication. Boul- 
laud believed that all cases had heart disease — regarded rheuma- 
tism, in fact, as the effect of the heart disease, or described the 
heart disease as one of the joints affected. Wells believed that 
heart complications occurred in about one-third of the cases. Sib- 
son and Fagge put their estimate at about fifty per cent — a ratio 
which represents the modern belief. 



RHEUMATISM. 



31? 



Heart disease reveals itself most frequently by a precordial 
pain, palpitation, and dyspnoea ; often, however, by none of these 
signs, so that the condition is discovered only by careful examina- 
tion of the heart, whereby a bruit is elicited or enlargement of the 
diameters recognized. Many cases recover from heart disease, but 
in more, permanent lesion is left. The heart is crippled for life. 

Rheumatism is sometimes marked by excessively high tempera- 
tures — hyperperexia, 110° to 118° F. These sudden elevations oc- 
cur in the course of the rheumatism. The disease does not begin in 
this way. This complication is recognized also by grave cerebral 
signs — delirium, convulsions, and coma. Most of these cases termi- 
nate fatally. 

Diagnosis. — Acute rheumatism is to be separated from pycemia, 
if it be not itself a mild pyaemia. There is in pyaemia usually a his- 
tory of an abscess or of a trauma. There 
is recurrence of chills and a more regular 
temperature curve, evidences of emboli else- 
where as well as in the joints, a protrac- 
tion of the disease over a longer time when 
not cut short by some grave complication, 
and an inamenability to treatment. Rheu- 
matism has in itself no special mortality, 
except in the few cases of hyperpyrexia. 

Aside from heart complications, rheu- 
matism has a mortality of about three per 

cent, so that the disease is more dreaded from its complications than 
from its own character. 

The treatment of rheumatism has been resolved in our day to 
the administration of salicin or the salicylates, which are looked 
upon as specifics. The treatment by alkalies, by acids, by blisters 
has fallen into disrepute in the presence of the salicylates. Clini- 
cal observation has shown that when a certain number of cases in a 
ward are treated by each of these methods, there is no appreciable 
difference between them and cases treated without any remedies, as 
to duration, complication, or mortality. 

Strieker, in 1876, called attention to the virtues of salicylic acid 
in the treatment of this disease, and Maclagan, of Dundee, an- 
nounced in this year that he had employed salicin as a specific since 
1874. The fact has since been unearthed that the Boers of South 
Africa were accustomed to administer to patients affected with rheu- 
matism teas made from the willow bark. Scepticism and incredulity 
have completely disappeared under the test of observation and ex- 
periment. It was soon seen that the remedy possessed the virtues 
ascribed to it by the discoverers or first observers — that the salicy- 




Fig. 166.— Hyperpyrexia of acute 
rheumatism. 



318 RHEUMATISM. 

lates cut the disease short, and, by abbreviating it, lessened in this 
way, and only in this way, complications on the part of the heart 
and acute pyrexias. The form of the remedy most in use in our day 
is the salicylate of soda. The following is a convenient recipe for 
quick effects : 

R Sodii salicylates 3 i j . 

Glycerinae | i. 

Aquae menthse piperitae § iij . 

M. S. Dessertspoonful to a tablespoonful every two to four hours. 

Equally efficacious is salicylic acid or salol, in powder or capsule, 
gr. v.-x. every hour or two. Obstinate cases require change of 
form. 

In a pronounced case with much suffering it is justifiable to ad- 
minister a dose of morphia subcutaneously, to be followed up imme- 
diately with salicylates, gr. vijss.-x. every hour at first, later every 
two hours. So soon as the pains lessen or the remedy produces any 
toxic effects, as nausea, ringing of the ears, vertigo, headache, the 
interval is to be increased or the dose diminished or the remedy 
stopped. Salol is contra-indicated in the presence of any suspicion 
of kidney disease. 

Pain usually yields in the course of five hours, and swelling be- 
gins to subside on the following day. The average duration of the 
disease under this treatment is about five days — a great gain over the 
six weeks at the time of Cullen. 

The best external treatment is fixation of the joint by pillows or 
bags of sand and the application to the surface of cloths wrung out 
of hot water. Cases marked by hyperpyrexia call imperatively for 
the cold bath. Apparently desperate cases have been thus rescued, 
as by Da Costa from a temperature of 106° F., by Draper and May- 
nard from 107.4° F., and by Fox from 108.4° F. Masses of ice were 
applied freely to the chest and abdomen in these cases, and brandy 
was given in abundance. 

Chronic Rheumatism. — Chronic rheumatism is a different af- 
fection. It is true that occasionally chronic results from acute rheu- 
matism, more especially in those cases in which acute rheumatism 
repeats itself often in the same joint, until there is at last left an 
irritation which remains. It is, however, only the exceptional case 
of acute rheumatism which becomes chronic. In the rule chronic 
rheumatism begins as such, and distinguishes itself by remaining a 
local affection. Chronic rheumatism belongs to the last half of 
life, whereas acute rheumatism begins in adolescence and begins to 
diminish at maturity. Chronic rheumatism begins at maturity and 
increases with advancing age. Chronic rheumatism is also, for the 
most part, a disease of the poorer class; when occurring among the 



RHEUMATISM. 319 

better class it may be attributed to local and, for the most part, dis- 
coverable conditions. Chronic rheumatism confines itself to one or 
a few joints, where it remains for months, for years, or for life. 
Chronic rheumatism is monarticular or olig articular in distinction 
from acute rheumatism, which is polyarticular. Acute rheumatism 
is said to fly from joint to joint. Chronic rheumatism remains fixed 
in one or a few joints. 

Pathology. — Continued exposure to cold is cited as the most fre- 
quent cause of this affection, and the exposed joints are the joints af- 
fected. Thus washerwomen are affected in the wrists, maid servants 
in the ankles, scrubwomen in the knees, coachmen in the wrists, 
porters in the feet, etc. The continued exposure of a side of the 
body, as by the apposition of the bed to a damp wall, or of the knees 
in writing at a desk, or feet as in riding, are frequent causes of this 
affection, which may disappear with removal of the cause. The 
pain in chronic rheumatism is not so acute or intense; it is rather 
subacute, and distinguishes itself by its protraction rather than in- 
tensity. Dull, boring, grinding, aching pains are the characteristics 
of chronic rheumatism, subject at times to more or less acute exacer- 
bation. Chronic rheumatism shows itself in a more or less fluctuating 
course, with relief of pain in warm or dry weather, increase or 
aggravation in raw or damp weather. Acute pains supervening in 
the course of chronic rheumatism show complication with the acute 
form of the disease. Chronic rheumatism, pure and simple, is un- 
attended with any sweating or complication on the part of the heart. 

Long-standing cases, especially under bad hygiene, show more or 
less per m a nent ch a n ge. The effusion, which may be very extensive, 
persists. The tendons about and membranes in the joint become 
more or less thickened and opaque. Various anchyloses show them- 
selves, but in the vast majority of cases there is no alteration of bone 
or cartilage to such degree as to produce organic deformity. De- 
formities of chronic rheumatism disappear or may be dissipated by 
massage, forcible extension, etc., especially under chloroform. The 
disease affects chiefly the larger joints, hip and shoulder and knee, 
wrist and ankle. Affection of the smaller joints implies for the 
most part a different disease — gout, nodular rheumatism, etc. 

Diagnosis. — Chronic distinguishes itself from acute rheumatism 
by the fact that it occurs in the latter half of life, mostly in old 
people; that it affects a single or a few joints, to which it remains 
confined; that it persists in spite of medication; that it is unattended 
by sweating, heart complication, or high fever. 

The prognosis quoad vdtam is good; quoad valetudinem is bad. 
Few diseases which are not in themselves fatal or involve organic 
change are so obstinate to treatment. Chronic rheumatism is for 



320 EHEUMATISM. 

the most part a disease of life. The hopelessness of any radical 
therapy is evidenced by the number of remedies recommended in its 
relief. Chronic rheumatism is, in fact, a fertile field for quacks, 
and every age abounds in plasters, liniments, and oils, in appeal to 
the credulity of the people, and in such profuseness of advertisement 
with us as to deform the face of nature. 

Treatment. — For the acute attacks of pain or exacerbations of 
inflammation the best remedy is salicylic acid, the salicylates, salol. 
For the chronic states the best remedy is the iodide of potassium. 
Most patients are more or less debilitated by age if not by the disease, 
so that alcohol, cod-liver oil, iron, quinine, hypophosphites are indi- 
cated in different cases. The virtues of local application depend 
upon heat and friction. Heat in the acute exacerbations is best 
applied with cloths wrung out of hot water, with poultices, hot water 
bags, etc. Fixation of the joint in these cases is of value, as by sand 
bags, pillows, splints, bandages. Such fixation, however, is not to be 
retained long enough to allow of anchylosis or atrophy from disuse. 
Hot-water baths at home or, better, at watering places, sand baths, 
peat baths, mud baths, are various applications of heat. Blisters in 
the neighborhood of the joints are the best derivatives, especially 
flying blisters — i.e., repeated in the vicinity of the joint — after the 
manner of the former treatment of acute rheumatism. Blisters de- 
rive materials which, reabsorbed into the blood, officiate as protective 
albumens, so that there is something more in blisters than mere 
counter-irritation. Liniments, sal- volatile liniment, opodeldoc, com- 
pound soap liniment, more especially applications containing chloro- 
form, opium, aconite, are stimulating embrocations. 

R Tincturse opii, 

Tincturae aconiti aa § ss. 

Chlorof ormi % i. 

Olei olivse , 1 ij. 

Or 

R Olei gaultherise, 

Olei olivag sive morrhuse aa § i. 

applied with friction, are good combinations. Arnica should be 
avoided, because it produces at times an obstinate eczema. 

A victim of chronic rheumatism, when able, should travel, should 
find a suitable climate in Georgia, the Carolinas, Florida, Nassau, 
the Bermudas, California, etc. 

Gonorrheal Rheumatism. — Gonorrhceal rheumatism is a 
separate form which has points in common with both acute and 
chronic, and points by which it may be separated from either. Thus 
it attacks for the most part the age of adolescence or maturity, 



RHEUMATISM. 321 

males four times more frequently than females, and is confined to a 
single or a few joints. The disease distinguishes itself by its sub- 
acute character. It occurs for the most part six to twelve weeks 
after the original infection, and persists for months, sometimes for 
years. When first observed it was thought to be a mere coincidence; 
but the frequency of its occurrence, more especially the continued 
recurrence in certain individuals, establishes it as a complication. 

It is as yet undecided whether gonorrhceal rheumatism depends 
upon the gonococcusor upon pyogenic organisms of subsequent, i.e., 
secondary, infection or invasion. 

The disease fixes itself for the most part upon the knee, ankle, 
or joints of the foot. These joints become swollen, sometimes im- 
meDsely swollen, without any acute pain because of the tolerance 
which is established under a slow development. Gonorrhceal rheu- 
matism, like chronic rheumatism, shows no sweating, has no cardiac 
complication, and leaves no deformity. Unlike chronic rheuma- 
tism, when finally cured it ceases, never to return, unless through 
new infection. 

The treatment does not differ radically from that already de- 
tailed. The constant current of electricity furnishes better results 
in gonorrhceal than in other chronic rheumatism. The sluggish 
character of the ailment calls for this stimulus, as well as that fur- 
nished by friction, massage, etc. The chronic gonorrhoea, gleet, or 
posterior urethritis, which may persist as a cause of continuous in- 
fection, should be treated until every trace of it disappears. 

Muscular Rheumatism. Pathology. — Muscular rheumatism 
is another of the varied forms of affection included under the term 
"rheumatism" as evidence of the vagueness and elasticity of the 
term itself. For muscular rheumatism confined to the muscles has 
nothing to do with the bones or with the joints, and the disease is 
called rheumatism only because it is marked by pain. Muscular 
rheumatism occurs at any time of life, but is noticed in certain 
forms, or particularly at certain periods of life. Thus affection of 
the cervical muscles belongs more particularly to youth ; of the in- 
tercostal muscles, to maturity ; of the lumbar muscles, to age. In 
many cases muscular rheumatism is simply the effect of trauma,, 
whereby muscular fibres are ruptured. This is the case especially in 
the sudden attacks of lumbago commonly known as stitches in the 
loins or back (Hexenschuss). The same thing is true also of many 
cases of intercostal muscular rheumatism, so-called pleurodynias. 
Sudden tensions, sudden wrenches, rupture individual fibrils and 
fibres. Other forms of the disease seem more directly attributable 
to exposure to cold. Thus torticollis, or rheumatism of deeper-seated 
muscles of the neck, may arise from sleeping opposite an open window 
21 



322 



RHEUMATISM. 



in a draught or sitting at an open car window in travelling. In 
many cases it may be assumed that poisons in the blood, micro- 
organisms or their products, hitherto innocuous, have become local- 
ized in individual muscles or their nerve centres by irritation or ex- 
posure. Such cases therefore may be said to be of infectious origin. 

A fine example of this muscular rheumatism is offered in 
trichinosis, which was formerly regarded as a kind of malignant 
rheumatism. Grawitz declares that in ninety per cent of cases of 
aggravated muscular rheumatism, so considered, he found on autopsy 
trichina? in the structure of the muscle. 

It may be readily understood that trichinae may be ingested in 
sufficient number to produce light or more or less severe muscular 




Fig. 167.— Torticollis (Gowers). 



rheumatism without previous or subsequent sign of their presence, 
and this origin may be assumed to exist all the more for the reason 
that the muscles affected—to wit, of the neck, of the chest, of the 
loins — are precisely the muscles most frequently invaded by trichinae. 

Morbid anatomy shows at times hypersemia, opacities of the 
sarcolemma, coagulations in muscular protoplasm, etc. ; but in most 
cases no lesion is to be found under the most careful inspection, and, 
inasmuch as the disease disappears to leave no trace, it must be be- 
lieved that in most cases no real lesion exists. 

Sympt oms.— Muscular rheumatism manifests itself chiefly in 
pain, spasm, in interference or abolition of motion, sometimes in dis- 
tortion. 

Occipitofrontal rheumatism is felt on motion of the scalp, and 
is distinguished from occipital and frontal neuralgia by the fact that 



DYSENTERY. 323 

in neuralgia tender points can be located in the course of the occipi- 
tal and trigeminal nerves. 

Torticollis (cervical rheumatism) shows itself in twisting of the 
head to one or the other side. It must be distinguished from affec- 
tion of the vertebrae or deep-seated neuralgias due to lesions in the 
spinal cord, from which affections it is, as a rule, readily separated 
by its more or less sudden origin, acute pain, short duration, and 
entire disappearance. 

Pleurodynia is distinguished from intercostal neuralgia by the 
absence of the tender points near the spine, in the axillary line, and 
near the sternum, to be discovered by pressure in neuralgia. 

Lumbago is the most common form of all. There is pain on mo- 
tion, especially aggravated in rising from a sitting posture or from 
bed after a night's rest. In a bad case the whole body is literally 
paralyzed by pain, and patients, more especially obese patients, lie 
helpless on the bed. 

The diagnosis must be established at the start. An acute in- 
fection must be eliminated. Thus, small-pox distinguishes itself by 
the severity of its pain in the loins and sometimes the back of the 
head. Tuberculosis, aneurism, caries of bone, tumors, need only 
be mentioned to be separated. A protracted lumbago in a young- 
person should always excite suspicion of caries of the spine, Pott's 
disease, which may reveal itself in a gibbus or in rigidity of the mus- 
cles of the spine. A very early diagnosis may be made with tuber- 
culin. 

The prognosis is good not only as regards the general health, 
but also the condition of the muscle, which is usually restored to the 
status in quo. 

The treatment is simple. Applications of heat and friction are 
the essential elements. Dry is better than moist heat. Hot-water 
bags, hot flannels, cloths over which a hot iron is passed, are domes- 
tic remedies. Dry cups often give quick relief. Excruciating pains, 
pains which prevent all motion, are best counteracted by deep injec- 
tions of morphia, gr. ^-\. Sometimes a subcutaneous injection, or 
the internal administration of phenacetin or antipyrin, gr. v., suffices. 
Friction with liniments, massage with alcohol, ointments of vaselin 
or lanolin, incorporating perhaps opium or aconite, according to 
formulae suggested, relieve the pain in most cases. More permanent 
relief is often afforded by faradization with a wire brush, with a roller, 
or with simple sponges, or by galvanization when the former fails. 

DYSENTERY. 

Dysentery (duz i'vrepoi, difficultas intestinorum) ; flux ; Ger- 
man, Ruhr. — An infection of the large intestine, of specific and non- 



324 DYSENTERY. 

specific (catarrhal) origin and form ; characterized by hypersemia, 
infiltration, and necrosis (ulceration) of its mucous membrane ; dis- 
tinguished by discharges of mucus, blood, pus, and tissue debris ; and 
attended with griping and expulsive pains (tormina and tenesmus). 

History. — Dysentery is one of the oldest known diseases.' The 
Ayur-Veda of India mentions forms of it, Hippocrates described it, 
and Herodotus relates how this disease and the plague decimated the 
army of Xerxes on the desert plains of Thessaly. Galen derived the 
discharges from the bile, Areteeus wrote ■ graphic accounts of the 
symptoms. The disease assumes epidemic proportion only in hot 
climates, and rages as a pestilence in army life, where it numbers 
more victims than the bullets of the foe. The accounts of this and 
allied disease, and the illustrations of its lesions, in the " Medical 
and Surgical History of the War of the Rebellion," vol. ii., make a 
lasting monument to the labor and learning of the editor, Joseph J. 
Woodward, of the United States Army. 

Etiology. — Dysentery is only a clinical expression, and the dis- 
ease is due to many causes. The most fruitful cause is drinking 
water contaminated by the discharges of dysenteric patients or per- 
haps by any decomposing matter. Exposure to cold, bad food, 
through nervous influence and by direct irritation of the mucous 
membrane, may produce individual cases of the catarrhal form. The 
disease is certainly intensified by crowd-poisoning, as in army life, 
pilgrimages, etc. 

Bacteriology. — Many micro-organisms are found in the dis- 
charges of dysentery. Two have been isolated as probable causes of 
the disease. One is the Amoeba dysenterise, the other a bacillus. 
Kartulis (1892) especially makes emphatic claim for an amoeboid 
body which he finds constantly in the discharges, and which has 
been found also in the contents of hepatic abscess. Kartulis culti- 
vated the amoeba in decoctions of straw, and inoculated it to produce 
certain symptoms of the disease. Lambl and Losch had remarked 
this structure previously, but had not ascribed to it pathogenetic 
property. Councilman and Lafleur of Baltimore, and Musser of 
Philadelphia, confirm in part the claim of Kartulis ; and Lutz of 
Honolulu probably defined the exact position of the amoeba as the 
cause of only certain individual (catarrhal) cases, but not of the epi- 
demic disease, which is more probably produced by a vegetable 
structure (vide Frontispiece, Fig. 17). The other is the bacillus 
described more especially by Ogata as the definite cause of an epi- 
demic in Japan. This bacillus, isolated and cultivated, produces, 
when introduced with the food or injected into the bowel of various 
animals, ulcers and haemorrhages in the colon, swelling of the 
mesenteric glands, and nodular masses in the liver and spleen. 



DYSENTERY. 325 

Symjjtoms. — Dysentery is a disease of the large intestine only, 
but it is usually gradually ushered in from a lighter form of gastro- 
intestinal catarrh. After a stage of incubation, which lasts from a 
few hours to a few days, symptoms of dyspepsia and diarrhoea set 
in or increase, attended with anorexia, heartburn, nausea, eructation 
or borborygmi, pain in the abdomen, and copious fluid discharges. 
Hereupon ensue the pains and discharges characteristic of the dis- 
ease. Violent griping and colicky pains (tormina) traverse the 
abdomen, with sickening sensations of depression. The desire of 
evacuation of the bowels (tenesmus) becomes intense and more or 
less constant, and the discharge itself is attended with little or no 
relief. At the same time the region of the rectum, intensely inflamed, 
is the seat of intolerable, burning pain, which becomes excruciating 
with the introduction of a speculum or the finger. 

Ordinarily the peculiar pains of dysentery first proclaim the 
character of the disease. The severe grinding, twisting pains (tor- 
mina) are more or less localized in the course of the colon, and hence 
surround or traverse the entire abdomen, the pains at the epigastrium 
being due to spasmodic contractions of the transverse colon. The 
patient in vain adopts various postures in relief, or sits with his 
hands firmly compressing the abdominal walls. The tormina are 
more or less intermittent or remittent, and are usually experienced in 
greater severity toward evening. During their acme the face wears 
the aspect of the intense suffering, which is expressed in outcries 
and groans. At the same time there is, upon pressure over the whole 
abdomen, more or less tenderness, which soon comes to be especially 
localized at the caecum or sigmoid flexure. 

The tenesmus (cupiditas egerendi) is a more distressing, and 
certainly more distinctive, sign of dysentery. It is the feeling of 
heavy weight or oppression, of the presence of a foreign body in the 
rectum, which demands instant relief. At the same time intense 
heat is felt in the rectum, which the patient likens sometimes to the 
passage of a red-hot iron. The desire of evacuation becomes as fre- 
quent as urgent. In well-marked cases the patient sits at stool half 
an hour or an hour at a time, straining until faint and exhausted, 
leaving the commode with reluctance, only immediately or very soon 
to use it again. 

Great depression is felt at the stomach at the same time, with 
nausea, occasionally with vomiting ; and strangury, with the dis- 
charge of only a few drops of scalding urine or blood from the blad- 
der, adds additional suffering to the disease. Retraction of the 
testicle and prolapsus ani, especially in children, are prone to occur 
in severe cases. 

The discharges may be copious, dark brown, thin, and highly 



326 DYSENTERY. 

offensive (bilious dysentery), may contain occasional hard, round 
fecal casts of intestinal sacculi (scybala), or may become more and 
more scant until with the most violent efforts only the minutest 
quantity is extruded of mucus, generally streaked or tinged with 
blood (rose mucus), like the rusty sputum of pneumonia. Later all 
effort at emptying the alimentary canal may be futile (dysenteria 
sicca), or the mucus may be pure or commingled with pus to remain 
perfectly colorless (dysenteria alba), or with blood in larger quantity 
(dysenteria rubra). In other cases, or at other periods in the same 
case, the discharges consist of fleshy masses composed of inspissated 
mucus or pus, blood, and tissue debris (lotura carnea). Sometimes, 
though rarely, the discharges consist of pure blood, but oftener of a 
copious turbid fluid which, on standing, separates into a clear upper 
layer of serum and a sediment of disintegrated lotura carnea. Or, 
lastly, the sediment is composed of small, round vitreous masses, 
evidently swollen by maceration to look like sago grains, which have 
been erroneously supposed to represent the liberated contents of the 
intestinal follicles. 

Neither the pain nor the prostration is so characteristic of 
dysentery as the stools, which, though of very varied nature, are 
nevertheless distinctive. After the discharge of the intestinal con- 
tents the first evacuation consists of mucus in the form of glairy, 
stringy matter, like the white of an egg, expressed as the result of 
the violent efforts at straining. The mucus may be pure or tinged 
with blood, but it is usually very scant in quantity, and stands in 
this regard in marked contrast with the violence of the efforts to 
secure its extrusion. It is the frequency of its discharge which con- 
stitutes an especial distress. Twenty to forty, even two hundred, 
times in the twenty-four hours the patient must go to stool. In the 
worst cases the patient sits at stool or lies upon the bed-pan the most 
of the day. 

The mucus is sooner or later mingled with pus or stained with 
blood. The presence of blood is equally characteristic of dysenteric 
stools. Usually it is intimately commingled with the mucus or pus, 
or forms the chief element of the copious so-called bilious discharge. 
The evacuation of pure blood indicates erosion of vessels low in the 
colon, often in the rectum itself, though enormous quantities of blood 
are sometimes voided from unbroken surfaces. 

Besides the mucus, pus, and blood, the dj^senteric stool contains the 
sloughs which have been torn off by violent peristalsis in cases of the 
diphtheritic form. Usually they are separated in shreds and frag- 
ments, but occasionally large sheets, even casts of a section of the 
colon, are voided en masse. These fragments consist for the most 
part of inspissated mucus, pus, blood, and tissue debris, but there is 



DYSENTERY. 



327 



no doubt that in some cases partially necrosed mucosa also enters into 
their construction. One enormous tubular cast fourteen inches long, 
preserved in our Army Medical Museum, was found to be "composed 
of pseudo- membranous lymph, in which no trace of the structure of 

the mucous membrane could 

be detected" (Woodward). 

There still remains to be 
mentioned the boiled-sago or 
frog's-spawn matter, whose 
origin has given rise to such a 
curious mistake. Not infre- 
quently these vitreous-looking 
bodies compose the bulk of the 
sediment in the stools of dys- 
entery, and even some of our 
modern authors, unacquainted 
with the more searching inves- 
tigations of Virchow, have re- 
garded them as expressed con- 
tents of intestinal follicles. 
Yirchow found that under the 
application of iodine they al- 
ways assumed a blue color. 
They are simply granules of 
starch ingested as food, to re- 
main partially or wholly undi- 
gested. 

The general condition of 
the patient suffers correspond- 
ingly. There may be fever 
or there may be none through- 
out the whole course of the 
disease, but the pain and dis- 
charges quickly exhaust the 
strength of the patient, and in 
severe or long-continued cases 
lead to emaciation and pro- 
found prostration. 

The skin is hot and dry; 
the tongue is heavily coated; 
the face wears an anxious expression. The abdomen is tumid with 
gases, or in more advanced cases sunken, discolored, and tender, 
especially in the course of the colon, whose thickened walls may be 
often felt beneath the emaciated surface. The anus is spasmodically 




Fig. 168.— Descending colon with sloughing 
pseudo-membrane (Medical History of the War 
of the Rebellion). 



328 DYSENTERY. 

constricted, or in the worst cases paralyzed, patulous, and livid or 
blue. Prolapse of the rectum is common in children, and excoriation 
of the perineum by the acrid discharge is not infrequent. 

Finally a typhoid state may set in or a pyaemia occur, when the 
discharges may become involuntary or unconscious, and brain symp- 
toms — insomnia, stupor, delirium, and coma — supervene ; or the 
patient may linger long enough to perish by simple exhaustion or 
marasmus. 

Under favorable hygiene the great majority of cases of catarrhal 
dysentery recover without special treatment in the course of from 
three to ten days, but specific dysentery has no definite duration and 
but little tendency to spontaneous cure. The worst cases are often 
quickly controlled by appropriate interference, and the most surpris- 
ing results may be sometimes obtained in cases of even years' dura- 
tion. On the other hand, a certain percentage of cases is character- 
ized by a defiance to every kind of treatment, including the last 
resort, a change of climate. 

An acute case of catarrhal dysentery generally subsides without 
lesions, and the natural duration of the attack may be much abbre- 
viated by proper treatment. Epidemic dysentery lasts from two to 
four weeks, or, becoming chronic, continues for years or for life, with 
exacerbations and remissions. 

Various complications are liable to occur in the course of the dis- 
ease. Three deserve especial mention — viz., affection of the joints 
(rheumatism), paralysis, and abscess of the liver. Perforation and 
peritonitis are always possibilities, and deformities of the colon, 
thickenings, and constrictions are not infrequently left. 

Morbid Anatomy. — Catarrhal dysentery shows hyperemia of 
the mucous surface, limited, in a large majority of cases, to the large 
intestine. The hypersemia is most marked in the lowest parts of the 
intestine, the rectum, or descending colon. The whole process may 
be arrested at this stage, or jt may increase to lead to softening of 
the cells and desquamation, the fundamental, anatomical character- 
istic of dysentery, by which process the submucous connective tissue 
is laid bare and ulceration results. In other cases a pseudo-mem- 
branous or diphtheritic process is developed. This condition may 
vary in intensity from a mere frosting of the surface to dense infil- 
tration of the entire thickness. Subsequent sloughing may ensue. 
The fall of the slough leaves the dysenteric ulcer. Its edges are ir- 
regular and ragged, its base uneven like a crater, and its surface is 
more or less covered with pultaceous debris. Perforation from such 
an ulcer is fortunately rare, but is the most frequent cause of perito- 
nitis in chronic dysentery. In rarer cases perityphlitis may ensue, 
or periproctitis with perineal abscess, or, finally, fistulse may form 



DYSENTERY 



329 



to burrow about and discharge themselves anywhere in or upon the 
surface of the abdomen, the lumbar region, or the thigh. The au- 
thor once saw in consultation a case of fistula which extended from 
the descending colon to the vagina. Through the opening made to 
discharge the pus from a fluctuating abscess pointing into the vagi- 
nal vault, an india-rubber tube was passed for six or eight inches. 
The patient died finally from marasmus. Ulceration shows itself in 
chronic dysentery in every grade and stage, from superficial denuda- 
tions to old cicatrizations. In bad cases the whole course of the 
colon from the ileo-coecal valve to the rectum may constitute one 
vast tract of suppuration. Chronic dysentery is marked by atrophy 
of glandular structure and hy- 
pertrophy of the wall of the 
bowel. 

Complications and Se- 
quel ce. — Pyaemia announces 
itself with a series of chills, 
followed by irregular tempera- 
ture, by the speedy occurrence 
of multiple abscesses in distant 
organs, venous thromboses, 
affections of- the serous mem- 
branes, pleuritis, pericarditis, 
and embolic pneumonia. Gan- 
grene of the intestine, which 
may occur as early as the third 
day of the disease, is evidenced 
by the signs of general col- 
lapse. 

Arthritis, when it occurs, 
shows itself, as a rule, in the 
second week of the disease, or after the disease has run its course, 
during the period of convalescence. All authors who admit it de- 
scribe the knee joint as being the most frequent seat of the affection, 
but acknowledge that it is mostly polyarticular; while there is much 
difference of opinion whether it ever presents the general signs of 
true rheumatism — pyrexia, diaphoresis, or its complications on the 
part of the heart. It usually lasts four to six weeks, but neither its 
occurrence nor its severity stands in any relation to the intensity of 
the attack of dysentery. It is probably to be regarded as a manifes- 
tation of a light pyaemia or septicaemia, as it is a frequent manifes- 
tation of this condition in or after scarlatina, puerperal fever, and 
the septic fevers of surgery, where it is a streptococcus infection. 

Paralvsis has been observed to occur after dvsenterv ever since 




Fig. 169. — Descending colon with oval ulcer: 
(Army Medical Museum). 



330 DYSENTERY. 

the days of Galen. It is usually confined to the lower extremities,, 
but may extend to and involve the upper extremities, by preference 
in the form of paralysis transversa (opposite arm and leg). 

Abscess of the liver gives rise to few distinctive symptoms, and is 
mostly recognized or suspected, in the absence of positive signs, by 
the persistence or obstinacy of dysentery. The ease and impunity 
with which aspiration may be performed in its recognition justify 
the use of it in every doubtful case. 

Dysentery may be further complicated by parotitis; by venous 
thrombosis (phlegmasia dolens); by diphtheritic deposits on other 
mucous surfaces, which Virchow dec]ares to be exceedingly rare; and 
by hydrops, which is oftener a concomitant of the period of conval- 
escence. 

Besides the deformities of the colon which may ensue as a conse- 
quence of ulceration or peritonitis, a long attack of dysentery is apt 
to leave a hypersesthetic or non-resistant state of the mucous sur- 
faces, so that every imprudence in exposure or in diet begets an in- 
testinal catarrh or a relapse of the disease. 

Diagnosis. — The tormina and tenesmus, the peculiar discharges, 
the rapid reduction of strength, leave no doubt as to the nature of the 
affection. The prevalence of an epidemic of the disease will often 
establish the character of a case even when all the signs are not pre- 
sent or when anomalies occur. Embarrassment in diagnosis only at- 
tends the recognition of catarrhal or isolated cases, and in these cases 
there may be a doubt as between dysentery and diarrhoea — if such a 
symptom can be called a disease — or typhoid fever, cholera, or some 
purely local affection of the rectum, cancer, haBmorrhoids, etc. In 
children difficulty of diagnosis may arise as between dysentery and 
intussusception. 

Dysentery is differentiated from that lighter form of intestinal ca- 
tarrh whose main symptom is diarrhoea by the presence of tenesmus 
in dysentery, as well as by its, mucous, muco-purulent, diphtheritic, 
and bloody discharges. Dysentery lasts longer than diarrhoea, as a 
rule, and does not yield so readily to treatment. 

Typhoid fever shows from the start brain symptoms, which are 
absent from dysentery ; has a typical temperature curve, whereas 
there may be no fever in dysentery, or, if any, it is of irregu- 
lar, remittent type ; is often prefaced by epistaxis and attended with 
bronchitis, both of which are absent in dysentery ; and exhibits 
ochre-colored, pea-soup stools altogether different from those of dys- 
entery. 

Cholera morbus distinguishes itself from dysentery by its sudden 
onset, its profuse vomiting and discharges, its violent cramps and 
speedy collapse. 



DYSENTERY. 331 

Cancer of the rectum can be usually felt, and haemorrhoids can be 
always seen, so that no difficulty should be experienced in the recog- 
nition of these cases. 

Intussusception occurs mostly in children, and has, in common 
with dysentery, vomiting, mucous or bloody stools, colic, tenesmus, 
nervous unrest, and prostration, so that a differential diagnosis may 
be impossible for a few days. The more strict localization of an in- 
tussusception, which may sometimes be felt as a sausage-like mass, 
most frequently in the right ileum and hypochondrium, the greater 
frequency and persistency of the vomiting and pain, the presence, 
visibly or palpably, of the invaginated gut at the anus or rectum, 
soon enable the careful examiner to recognize the case. 

Prognosis. — The prognosis of dysentery varies between extremes. 
Catarrhal cases are mostly so mild as to terminate of themselves, un- 
der favorable hygiene, without special treatment. On the other 
hand, no known disease has a more frightful mortality than dysen- 
tery in some of its epidemics, especially in army life. It was this 
class of cases which Trousseau had in mind when he called dysentery 
the most murderous of all diseases. Sixty to eighty may be the ap- 
palling percentage of death in these cases. 

Complications on the part of the nervous system, the status ty- 
phosus, pyaemia, and great prostration necessarily render the prog- 
nosis grave, yet even these cases are not necessarily fatal. Cases have 
recovered after complete paralysis of the sphincter ani. The recogni- 
tion and discharge of an hepatic abscess relieve the patient from the 
dangers of this complication. Peritonitis alarmingly aggravates the 
prognosis, and perforation is almost of necessity fatal. 

Prophylaxis. — The improved sanitation of modern times has al- 
ready diminished the frequency and mitigated the severity of epi- 
demics of dysentery ; and this fact, which is only an accidental ob- 
servation, as it were, gives the clue to the means of its further pre- 
vention. 

The selection of proper sites for camping grounds, barracks, and 
hospitals, the prevention of overcrowding in tenement houses, ships, 
and jails, the regulation of sewage, care for the food and drink, the 
observation of the strictest cleanliness by authoritative control — all 
these are general measures which suggest themselves in the prophy- 
laxis of this or any disease. 

In the management of individual cases the first precaution is to 
prevent the dissemination of the disease, as this protection of others 
secures also for the individual patient the most favorable hygiene. 

The bedding must be frequently changed ; the windows kept open 
to secure free ventilation, which, in the light of existing knowledge, 
is the only true disinfectant; and all the furniture of the sick-room, 



332 DYSENTERY. 

especially including the receptacles for the discharges, must be kept 
perfectly clean. For this purpose the best purifier is boiling water. 

The drinking-water should be secured, during an epidemic, from 
the purest possible source ; and if good drinking-water cannot be had, 
what there is should be thoroughly boiled. 

The discharges should be properly mixed with sawdust or some 
combustible substance and burned ; or, if this be impracticable, should 
be buried in the soil a few feet below the surface, and not emptied 
into water closets or privy vaults used by others. 

Such articles of food should be abjured as have a tendency to 
produce intestinal catarrh. So unripe fruits, vegetables which 
readily undergo fermentation — in short, all indigestible substances — 
should stand under ban. But no prohibition should be put upon ripe 
fruits or simple, nutritious food of any kind. Lastly, liable individu- 
als should protect themselves from catching cold. 

Treatment. — The first requisite in the treatment of an individual 
case is perfect rest. Patients with even the lighter forms of catarrhal 
dysentery should observe the recumbent posture, and cases of more 
serious illness should be put to bed. Rest in bed, an exclusive diet 
of milk — which should always have been boiled — and the time of a 
few days is sufficient treatment for the mildest case. Where there 
is objection to milk, meat soups, with or without farinaceous mat- 
ters, rice, barley, etc., may take its place. 

A case which is somewhat more severe will require perhaps a light 
saline laxative — a Seidlitz powder, a dose of Rochelle or Epsom salts 
in broken doses — or a tablespoonful of castor oil or five to ten grains 
of calomel, to effect a cure. For the relief of the pain of the lighter 
cases nothing is equal to tincture of opium, of which five to ten drops 
every three or four hours, in a tablespoonful of camphor water acidu- 
lated with a few drops of hydrochloric acid, will generally suffice ; 
Dover^s powder in broken doses, one'to three grains, with five to 
fifteen grains of bismuth or soda, or both, is a good substitute for a 
change. Salol in tablet gr. v., or hydronaphthol in keratin-coated 
pill gr. v., every hour or two, sometimes cures the disease. 

The successful treatment of dysentery in any form depends upon 
a recognition of the fact that the disease is local as to its seat and is 
probably specific as to its cause. Anodynes relieve effects, but laxa- 
tives must remove the cause. Consequently the most rational treat- 
ment of the severer cases is the irrigation of the large intestine and 
the thorough flushing out of its contents. Since Hegar has recently 
shown how the whole tract of the large intestine can be thoroughly 
inundated and flushed with a common funnel and rubber tube, the 
practice has continually gained ground, until it is now admitted as 
the most valuable method of treatment. Wood of Philadelphia, 



DYSENTERY. 333 

and later Mackenzie of London, reported a number of cases in which, 
irrigation of the bowel with large injections medicated with nitrate 
of silver, 3i.-Oi., was attended with the most surprising results, 
sometimes but a single injection effecting a cure ; and the author has 
reported a case, almost in articulo mortis, where complete cure fol- 
lowed the irrigation of the bowel — on three occasions with three 
pints of water containing three drachms of common alum. This 
case was all the more instructive from the fact that a relapse had 
occurred after very striking but only temporary relief had been ob- 
tained with the nitrate of silver, the alum having been substituted 
simply on the ground of expense. Usually half a drachm to the pint 
will suffice for either drug. Tannin in one-per-cent solution is a good 
substitute. 

The object is to introduce as much cold water as possible without 
producing too much pain. The large intestine of an adult holds, on 
an average, six imperial pints, but in the author's experience not 
more than three or four pints can be, as a rule, safely introduced. 
The patient should lie upon the back or left side, with the hips ele- 
vated and the head low, while the injection is slowly introduced 
from a funnel, fountain, or a bulb syringe whose nozzle is thoroughly 
anointed with vaselin. In the absence of a thoroughly competent 
assistant the operation should be performed by the physician him- 
self, for the proper use of an irrigating enema is a pmctice which re- 
quires both judgment and skill. When pain is experienced the further 
influx of the fluid should cease for a few minutes, when it ma}' be 
resumed again and again until the largest possible quantity is intro- 
duced. It is impossible to overestimate the value of this treatment 
in cleansing, disinfecting, and constringing the foul and flabby sur- 
face of the whole seat of the disease. As was said by Hare: "It 
changes a huge internal into an external abscess, and enables us to 
cleanse the bowel of its putrid contents.'' 

Of all the remedies which have been recommended in the relief of 
dysentery, besides the irrigation method, but one — ipecacuanha — de- 
serves the name of a specific. 

The remedy is best administered in large doses, gr. xx.-xl., and 
should be repeated every four to twelve hours until permanent good 
effects are secured. A dose of fifteen to thirty drops of tincture of 
opium, or morphia one-fourth grain hypodermatically, will best pro- 
tect the patient from too great exhaustion. The beneficial results are 
mostly obtained in the acute cases, though surprising results sometimes 
follow in cases of very long standing. Should the remedy fail to be of 
service in the course of twenty-four hours, it should be discontinued. 

Suppositories of opium and belladonna with cocoa butter quickly 
relieve severe tenesmus. Clysters of nitrate of silver gr. iv. and 



334 



DYSENTERY. 



water § v. (Duchs), or with a few drops of tincture of opium (Ber- 
ger); of ipecacuanha (Begbie and Duckworth); of laudanum and 
starch (Sydenham, Abercrombie) ; of the various astringents, espe- 
cially acetate of lead gr. viij. and water 3 iv., may be tried in obsti- 
nate, more especially chronic, cases. 

Local inspection of the rectum by means of the speculum may 
possibly reveal an ulcer, which is the chief or sole cause of the tenes- 
mus and bloody discharge. Maury reports such a case, in which the 




Fig. 170. 
T3ellioD). 



-Cicatrices of diphtheritic ulcers in the colon (Medical History of the War of the Ee- 



ulcer was deep enough to hide a small sponge. In such cases topical 
treatment may effect a cure. 

Dilatation may suffice to overcome a stricture in the rectum, the 
result of cicatricial contraction, or colotomy may be necessary in 
cases more refractory or situated higher in the bowel. Post reported 
a successful colotomy, with the formation of an artificial anus in the 
left lumbar region, in such a case. Perforation calls for immediate 
laparotomy. 

In all cases of pronounced prostration stimulants are to be freely 



CHOLERA. 335 

aised; and of all stimulants alcohol is the best, as it has also nutritive 
.and antiseptic properties. Alcohol is thus trebly indicated in the 
treatment of dysentery, but the choice of the form and strength will 
be a matter of judgment in the individual case. 

Where life is imperilled by haemorrhage or anaemia from any 
cause, a forlorn hope is offered in subcutaneous transfusion of salt 
water (boiled), one drachm to the pint. 

Abscess of the liver is best treated by aspiration or hepatotomy, 
rheumatism by the salicylates, and paralysis by the constant cur- 
rent of electricity. 

Obstinate cases of chronic or continually recurring dysentery are 
thoroughbr cured only by a sea voyage, a sojourn at the sea shore, a 
mountain excursion, or a permanent change of climate. 

CHOLERA. 

Cholera (x°^V> bile, ptco, to now, from ancient erroneous concep- 
tion, as it is precisely the bile which does not flow) ; Indian or Asiatic 
cholera, as distinct from cholera nostras, cholera morbus. — An exqui- 
sitely acute infection of the intestines, caused by a spirillum ingested 
with the drink, characterized by profuse discharges like rice water 
from the bowels and stomach, congelation of the blood, suppression 
of urine, huskiness of voice, cyanosis, cramps and collapse ; or re- 
action and recovery ; or at times, later, a typhoid state. 

History, Geography, etc. — Asiatic cholera was unknown to the 
old Greek writers. They applied the term to our cholera morbus or 
cholera infantum. Yet the disease has had its home and haunt from 
time immemorial on the banks and swamps of the Ganges and Bra- 
maputra, where it finds the necessary heat, moisture, and decompo- 
sition to perpetuate its cause. But it never broke its leash until 
1817, when it appeared in Jessora. and later Bagdad, 1819, and tra- 
velled thence across Persia to the Trans-Caucasus (TifTis), whence it 
was carried to Astrakhan, September, 1823, and was here effectually 
killed by the extreme cold of October of that year. The next out- 
break made itself memorable as the first real pandemic of the dis- 
ease. It started from the Ganges in 1826, reached China in 1828, 
whence it was shipped to Orenburg and Astrakhan, 1830. Thence it 
reached Russia in 1831, and in the same year invaded Prussia, ap- 
pearing for the first time in Berlin and Hamburg. From Hamburg 
it was carried to England, and thence by Irish emigrants to Canada 
(Quebec) and the whole of North America in 1832. This attack did 
not cease until 1837. The third pandemic started in India in 1848, 
reached China, Persia, European Turkey and Russia, Siberia, Ger- 
many (Hamburg), Hull, and thence in the same year New York 
and New Orleans and the whole of the United States. This epi- 



336 CHOLERA. 

demic visited Norway, Sweden, and Denmark for the first time in 
1853. The disease did not die out in Europe until 1861. The fourth 
pandemic, 1863-75, was carried from the Ganges to Bombay, by 
pilgrims also to Mecca, Suez, Egypt, by ship to Constantinople and 
Marseilles. It reached the United States in 1866. In 1884 cholera 
appeared in Toulon, an importation from Egypt, and traversed Hun- 
gary, Spain, and Italy, reaching South America from Genoa. The 
epidemic of 1890-92 followed both northern and southern courses, 
reaching the west of Europe in 1892. This outbreak, highly fatal at 
Hamburg, was successfully quarantined at New York Harbor in 
1893. The Cholera Bacillus was discovered by Koch in India in 1884. 

Etiology. — Cholera is a purely " water-borne disease" (E. Hart). 
Certain places are always visited, others often spared by visitations 
of cholera. Porous soils, sinking subsoil water by opening access 
to oxygen, more especially by contaminating wells and drinking- 
water, favor the development of cholera. Cities of valleys and 
plains are oftener or more severely attacked than those of eleva- 
tions or mountainous regions. Assemblages of multitudes in pil- 
grimages, camps, etc., especially under bad hygiene, favor the 
spread of the disease. Cold weather inhibits and checks the growth 
of the spirillum and puts a stop to an epidemic. Of individual con- 
siderations age is important. The young are likely to escape alto- 
gether or suffer a mild attack, largely on account of active (acid) 
gastric juice and rapid peristalsis, which destroy and expel the cause 
of the disease. The old and enfeebled suffer most. Imprudence in 
diet and drink (alcohol), bad habits of any kind, catarrh of the sto- 
mach or intestines, dyspepsia and diarrhoea, predispose to the dis- 
ease. That amount of fear which leads to prudence in diet, care of 
the drinking-water, including milk and all other drinks, protects 
against the disease. Excessive or abject fear increases the liability. 

Bacteriology. — The cholera spirillum is a curved rod like a comma, 
the " comma bacillus," flagellated, endowed with motion, 1-2 ft long 
(vide Frontispiece, Fig. 14). J It is an aerobe, though it may still de- 
velop in the absence of oxygen, with optimum temperature at 85°- 
106° F. It ceases to grow at 60° F., but perishes only after thor- 
ough freezing. It is very sensitive to acids, is speedily killed by 
sublimate, carbolic acid, etc., and quickly dies under desiccation. 
It grows in all kinds of culture soils, luxuriates in fresh milk, but 
perishes at once so soon as the milk becomes sour. It lives on bread 
(rye) one day, on bread wrapped in paper three days, on bread under 
a glass cover seven days, on the surface of feebly acid butter four to 
six days, in beer twenty-four hours, in acid (0.7 per cent) wine but 
fifteen minutes. It perishes at once in lemonade (Uffelmann), which 
is therefore a better drink than even dilute muriatic acid during the 



CHOLERA. 337 

prevalence of cholera. The spirillum freshly discharged is feeble. 
It gains in tenacity out of the body, so that it resists the action of the 
gastric juice. It lives longer in contaminated than in pure water. 
It has been demonstrated in well water after thirty days (Koch), 
and in harbor (sea) water eighty-one days (Xicati and Rietsch). 
Koch found it in India in streams contaminated 
by the washing of cholera linen and in tanks i V ^^ *" 

used for drinking-water. Fresh aerobe cul- u'l^ or V * 

tures of the cholera spirilla develop a special v 1 A^^'i 
poison of extraordinary intensity. Thymol, 1 t Y* <, w 
chloroform, desiccation, which destroy the spi- «"% ** ^ "* 

rilla, do not attenuate the virulence of this poi- 
son. Most of the symptoms of cholera are attri- *** m.-Comma bacillus 

_ . . of cholera, pure culture. 

buted to the action of this cholera toxme. 

The cholera spirillum is usually easily demonstrated in the dis- 
charges by fuchsin or methylene blue. A rice-water flocculus is 
often almost a pure culture. Cases of doubt may be determined by 
cultures. A quantity of the discharge is added to a double quantity 
of alkaline bouillon and kept at a temperature of 100° F. Colonies 
which quickly show on the surface may be transferred to plate cul- 
tures. On gelatin plates the colony grows as flat, yellow discs. 
which in one day fluidify the soil and show under the lens a granu- 
lated appearance, as if the surface had been strewn with small pieces 
of glass (Koch) (vide Frontispiece, Fig. 11). Stick cultures show a 
line of fluidified gelatin, expanding at the top to a small funnel, a 
point of distinction from simulating bacteria (vide Frontispiece, 
Fig. 8). The addition to bouillon cultures of five to ten per cent 
common nitric acid develops a violet color. The addition of sul- 
phuric acid, with subsequent neutralization with soda, develops a 
Burgundy red, the so-called ;i cholera red." 

Sy)nj)to)ns. — Cholera begins suddenly, often in the night, with 
diarrhoea, which voids first the contents of the bowels stained with 
bile; later, in the course of an hour or two, the characteristic alkaline 
rice-water discharges. The discharges are voided without effort, 
pain, or tenesmus. They gush from the body in such quantity, fif- 
teen to twenty during the day, as to drain the blood. Vomiting 
now sets in — at first of the contents of the stomach, with bile regurgi- 
tated from the duodenum; later, through an incontinent pylorus, of 
the same rice-water contents of the small intestine. The vomiting is 
also without effort or strain. It gushes from the mouth and is some- 
times projected several feet from the body. The patient soon falls 
into collapse, with precordial constriction, intense anxiety, unap- 
peasable thirst, heart failure, and faintness. During the attack 
cramps develop in the calves of the legs, later in the arms and 
22 



338 CHOLERA. 

abdomen, not suddenly or universally at a stroke, as in tetanus, but 
more gradually, successively, one after another, to the indescribable 
torture of the patient while they last. 

The disease is now at its height. The surface is cold, tinged 
with blue on a gray ground. A wide black halo lies about the 
deep-sunken eyes. The nose is pinched, the lips livid, the tears dried 
up, the cornea grows opaque. The breathing is oppressed and diffi- 
cult; the very breath is cold. The voice is husky, reduced to a 
whisper, and lost. The urine is reduced more and more. Finally 
the kidneys fail entirely. There is often complete anuria, generally 
for a period not longer than a day or two, in fatal cases often for the 
greater part of a week. The discharges continue profuse. The 
anxiety gives way to apathy. The mind, clear from the start, be- 
comes clouded. The heart's action grows feebler and feebler, cya- 
nosis increases, and the patient dies of asphyxia. 

This scene represents the first stage, or the stage of asphyxia. 
It lasts from three to thirty six hours, and is followed, in cases which 
recover, by the second stage, the stage of reaction. The discharges 
now cease in frequency, cease altogether, or become natural and are 
again tinged with bile. The pulse grows stronger, the surface 
warmer or bathed in sweat, the secretion of urine is re-established, 
is sometimes increased beyond the normal amount (polyuria), the 
appetite returns, the patient gains strength; convalescence is estab- 
lished. 

Unfortunately, in a certain percentage of cases the reaction does 
not stop at the standard. It goes beyond; it becomes excessive. 
Fever increases, the mind becomes clouded, the tongue is coated, the 
lips are covered with sordes, the voice is again reduced to a whisper, 
the kidneys fail, and the patient, under the signs of uraemia or tox- 
aemia from chemical products of the bacillus, sinks into the danger- 
ous state known as the cholera typhoid. 

Eruptions of various kinds may now occur: erythema, roseola, 
urticaria, first on the forearms and wrists, later on the face and body, 
rarely widely scattered anywhere; or various more dangerous com- 
plications or sequelae may develop. Thus croupous or catarrhal 
pneumonia, meningitis, decubitus, gangrene, erysipelatous inflam- 
mation, diphtheritic, ulcerative, and destructive processes some- 
where in the course of the alimentary canal, may occur to threaten 
or take life which has survived the disease itself. 

Forms. — During the prevalence of an epidemic a great many 
cases develop nothing more than a more or less sharp diarrhoea with 
dyspeptic signs lasting over the greater part of a week. These are 
the cases of so-called cholerine — little, mild, or light cholera — most 
dangerous cases in the dissemination of the disease. These patients 



CHOLERA. 339 

go about soiling linen, and through defective sewerage contaminating 
drinking-water with their dejections, until cases multiply to constitute 
an epidemic. In other cases the attack is foudroyant. Such at- 
tacks may take life in the short space of two hours. Between these 
extremes are attacks of every grade of intensity. More rare are the 
cases in which no discharge at all appears — cases of so-called cholera 
sicca, dry cholera. Many of these cases succumb rapidly. The 
paralyzed bowel is found filled to distention, unable to expel its 
contents. 

Morbid Anatomy. — Post-mortem rigidity sets in soon; decompo- 
sition is delayed. The body is cold and blue. Emaciation may be 
pronounced. The skin is shrunken. The muscles may show post- 
mortem tremor (fibrillation), whereby members of the body or the 
whole body may be moved. The intestine, more especially the 
ileum, is distended with the rice-water fluid, which is grayish white, 
odorless, and full of flocculi. The mucous membrane is hypersemic 
and swollen, or cedematous, macerated, and denuded of epithelium. 
Ecchymoses are abundant; diphtheritic deposits, ulcerations are not 
infrequent. The internal organs are drained of blood and dry. The 
blood in the right heart is often thick like tar. The spleen is small, 
its surface wrinkled. In protracted cases the kidneys show evidence 
of profound lesion in degeneration of the epithelium of the urinary 
tubules, as a result, not of stasis, but of poisoning by the cholera tox- 
ine (Aufrecht). 

The diagnosis is easy in the presence of an epidemic, though 
cases of poisoning by the metals, especially by arsenic, and cases of 
heat stroke, have been included in cholera times. First cases are dif- 
ficult, though these cases are not so dubious under the present rapid 
dissemination of news. The true physician, who hesitates to alarm 
a community unnecessarily, will not be deterred by fear of adverse 
criticism from declaring a diagnosis. The safety of a community 
depends upon the recognition of the first cases. The peculiar rice- 
water discharges, cramps, heart failure, cyanosis, and rapid collapse 
distinguish the clinical history. Cholera nostras occurs more espe- 
cially in late summer and fall, in the absence of an epidemic or news 
of the advent or approach of true cholera. It begins with vomiting, 
as a rule; purging follows later. The discharges of cholera morbus 
are not like rice water, as a rule, though such discharges may occur. 

The diagnosis really rests upon the recognition of the cholera 
spirillum in the discharges or upon linen. The best demonstrations 
are made with the carbol-fuchsin solution. Caution* must be used 
with alcohol in withdrawing the water, as the comma bacillus very 
readily gives up its color (Neelsen), It is not colored by the method 
of Gram. For practical purpose the inoculation of gelatin in a clean 



340 CHOLERA. 

saucer will suffice ; for the appearance of the dotted or stippled sur- 
face, the " broken glass " surface, from irregular fluidification of the 
gelatin in the short space of twenty-four hours, is absolutely pecu- 
liar to the comma bacillus of cholera (Pfeiffer). The tube tests, 
which take a longer time, are thus rendered superfluous. But super - 
flua non nocent. The cholera spirillum is differentiated from simu- 
lating structures, those of Finkler- Prior, Deneke, Escherich, etc., by 
different action on culture soils. 

To confirm the diagnosis of cholera a flocculus is picked from 
the faeces or from the linen with a platinum needle previously steril- 
ized at a white heat. This flocculus is introduced into a test tube 
partly filled with warm, 8(3° F., agar-agar, previously sterilized by 
boiling. The particle is distributed throughout the gelatin. Three 
or four drops are now taken from this tube and inserted into a sec- 
ond tube, and from this second tube in like manner into a third tube. 
The contents of these three tubes are now poured out upon the sur- 
face of three glass plates which have been previously sterilized by 
washing in a sublimate solution and thorough heating for a long 
time. Here the gelatin is allowed to set. The three plates are now 
banked one above the other, and covered in by a bell glass cover — 
three soup plates will suffice — whose interior is kept moist and pure 
by being lined with a layer of filtering paper moistened in a subli- 
mate solution. Colonies which form on the third day are now ex- 
amined under the microscope, and suspicious bodies are proved with 
the stick cultures in tubes filled with solid gelatin (agar). Studies 
of motion are also made in hanging drops. Information furnished 
by all these methods establishes the diagnosis. 

Poisoning by the metals, corrosive sublimate, more especially 
arsenic, is eliminated by the detection of these substances by chemi- 
cal tests. Heat strokes show no comma bacilli in the stools. 

The absolute diagnosis of cholera is determined at Koch's Insti- 
tute, Berlin, in six ways 3 1, by microscopic examination ; 2, by 
peptone culture ; 3, by gelatin culture ; 4, by agar culture ; 5, by 
the cholera- red (indol) reaction ; 6, by inoculation of guinea-pigs. 

1. The microscopic examination alone declares the diagnosis in 
half of all cases. A rice-water floccule on the cover glass stained 
with diluted Zieh?s f uchsin solution is seen, in the case of true cholera, 
to show numbers of comma bacilli, all disposed in the same direction, 
that is, apparently following each other like a school of fish in a slug- 
gish stream. This appearance is itself characteristic. 

2. The peptone culture is prepared by adding to a sterilized 
watery solution of peptone and common salt, each one per cent, as 
much soda as will make the solution strongly alkaline. Examina- 
tion for bacilli is made in twelve hours after inoculation of the soil. 



CHOLERA. 341 

3. The gelatin plate culture — i.e., twenty per cent gelatin in oven 
at 22° C. — shows the characteristic appearance in fifteen to twenty- 
two hours. 

4. The agar plate culture displays colonies in eight to ten hours. 

5. The cholera-red (indol) reaction is obtained by adding a nitrate 
to the peptone culture soil containing pure cultures of cholera bacilli. 
Sulphuric acid (pure) develops the peculiar color. 

6. The inoculation test consists in the introduction of a platinose 
of 1.5 milligrammes agar culture with 1 cubic centimetre sterilized 
bouillon into the peritoneal cavity of a guinea-pig of three hundred 
to three hundred and fifty grammes weight. The animal perishes 
in a short time with typical symptoms of poisoning and fall of tem- 
perature. No other curved or spiral bacteria have yet been found 
which will in a dose so small produce anything like the same 
symptoms. 

Finally, the drinking-water should be tested with the peptone cul- 
ture soil, and the numerous bacteria thence derived examined and 
tested as before. Cholera bacilli were thus disclosed in the river 
Elbe and in wells, etc., in the epidemic of 1892 in Hamburg and 
Altona. 

The prognosis is always grave. The mortality, excluding 
cholerine and the lighter forms of diarrhoea, ranges about fifty per 
cent. It is always highest in the beginning of an epidemic, and 
greatest among the aged and enfeebled. 

Prophylaxis consists in quarantine at sea. There is no excuse 
for cholera in lands separated by oceans. A sea blockade as effec- 
tive as that of the South in the late war would suffice to bar out 
cholera, and the expense entailed would be a trifle compared with the 
cost of an epidemic. Land quarantine is useless because necessarily 
ineffective. Detention of passengers from infected ports in quaran- 
tine, especially of all individuals affected with diarrhoea, and disin- 
fection of all soiled linen under dry heat, 250° F., constitute the 
best prophylaxis. The thorough cleansing of cities, with house-to- 
house inspection by intelligent sanitary officers armed with author- 
ity and, if necessary, provided with means of indemnification for 
destruction of dangerous property (clothing, bedding, etc.), with 
care for pure drinking-water and discharge of sewage, has much to 
do with the prevention of the disease. During the actual preva- 
lence of an epidemic people best protect themselves by prudent 
habits, personal cleanliness, and the use of pure drinking-water. 
They who can afford it may partake only of the mineral or carbon- 
ated waters or light wines ; all other waters should be thoroughly 
boiled. The milk should be boiled. The digestion should be kept 
sound by care as to diet, if necessary by the use of dilute hydro- 



342 CHOLERA. 

chloric acid gtt. x-xx. in a wineglass of cold water before meals. The 
slightest diarrhoea demands prompt attention. The discharges 
of patients should be buried, or mixed with sawdust and burned. 
Soiled linen as it accumulates must be kept in a five-per-cent solution 
of carbolic acid and later subjected to dry heat. Utensils, bed- 
pans, etc., should be washed out with carbolic acid solution. 

Immunity. — Brieger, Wassermann, and Kitasato injected into 
guinea-pigs cholera cultures in a soil of thymus-gland tissue heated 
to 65° C. fifteen minutes and cooled in an ice chest twenty-four 
hours. The animals were thus rendered absolutely immune to viru- 
lent cholera cultures, surviving the introduction of three times the 
quantity fatal to control animals. 

Klemperer induced immunity with cultures attenuated by heat, 
also by the galvanic current. Blood serum from animals immunized 
in this way produced immunity in other animals. Haffkine secured 
from pure cultures of cholera bacilli a so-called anti-cholera vaccine, 
with which he inoculated himself and other men, securing protection 
against the virulent disease. All these methods are now under trial. 

Treatment. — The most important element in treatment is the 
arrest at once of diarrhoea by an opiate, which is made more effi- 
cacious by the addition of an acid. 

IjE. Tincturre opii 3 i. 

Acidi hydrochlorici diluti gtt. xl. 

Aquae camphorse § iv. 

M. S. A tablespoonful every hour or two. 

Rest in bed must be absolute. A mild case may be controlled by 
a suppository of opium, one grain, especially at night. A more se- 
vere case calls for morphia subcutaneously, in dose of one-fourth 
grain to an adult. To children the tincture of opium must be given 
with caution. One drop is the dose for the first year. A child over 
two years of age may take a teaspoonful of the mixture just pre- 
scribed. The algid state must be counteracted by heat. The pa- 
tient may be wrapped in blankets, with bags, jugs, and bottles of hot 
water along the spine, sides of the body, and at the feet. Hot sand 
bags retain heat a long time. The intolerable thirst may be ap- 
peased with cracked ice, and the patient may drink freely of pure 
carbonated waters. Vomiting is best controlled by chloral. Mus- 
tard plasters to some extent allay epigastric pain. Friction helps the 
cramps somewhat. Quicker relief is offered in very bad cases by 
injections of chloral, gr. v., deep into the substance of the muscle. 
Persistent diarrhoea, vomiting, and cramp may be stilled by a re- 
peated hypodermatic injection of morphia. Irrigation of the whole 
bowel with a hot one-per-cent solution of tannic acid (entero-clyster) 



CHOLERA. 34 



or with very weak sublimate solutions 1 : 100,000 is all the more 
indicated because the rice-water discharges contain so little albumen 
to weaken the parasiticidal effect. In the absence of any specific 
address to the toxine in the blood, attempt is made to counteract 
the drain by transfusion with salt water, which is best practised sub- 
cutaneously. Samuel recommends a solution of the strength of one- 
half drachm to the pint of sterilized, warm, 105° F., water injected 
continuously at the infraclavicular fossa. Cantani prefers a solu- 
tion of common salt 3i., carbonate of soda gr. xlv., distilled water 
one quart, introduced at the sides of the body (loins), behind the ribs, 
by means of a fountain syringe. The skin is punctured with a fine 
canula, the trocar withdrawn, the tube adjusted, and the fluid al- 
lowed to flow, absorption being hastened by massage. Cantani calls 
the process, which may be repeated on the other side, a hypoderma- 
tic clyster. There is no doubt of the great value of these injections, 
whereby patients recover at times even from states of asphyxia and 
unconsciousness. The salt solutions not only fluidify the blood, but 
also neutralize, to some extent, the poisonous action of the cholera 
toxines upon the nervous system. Unfortunately, the restoration 
does not hold. 

Collapse is met with alcohol (brandy) by the mouth, also by sub- 
cutaneous injection. Keppler recommends for this purpose : 

B Sodii bicarbonatis 7.0 

Alcohol absoluti 10.0 

Aquae destillatae 1000.0 

injected anywhere under the skin, warm, 37° C. (100° F.), fifty cubic 
centimetres, at first every minute, later, so soon as the pulse is per- 
ceptible, every five minutes, then every half hour. Camphor is also 
a good excitant : 

B Camphor rasurarum . . 3 ss. 

Ether, sulphuric 5 iiss. 

M. 

Inject ten drops at a dose. During the stage of reaction the at- 
tempt is made to secure free action of the kidneys, especially by 
copious draughts of warm water, hot baths, diuretics, etc. The 
treatment of the cholera-typhoid stage is wholly symptomatic and 
does not differ from that of typhoid fever itself. During convales- 
cence the diet should be fluid — milk, soups, diluted egg, thin cus- 
tards, gruels, etc. — for a week or more. 

CHOLERA MORBUS. 

Cholera morbus, nostras; European, sporadic cholera (xo\r/, bile, 
peoj, to flow, because the discharges are stained with bile) ; in infants, 



344 CHOLERA. 

cholera infantum. — An acute infection of the stomach and intes- 
tine, sporadic, occasionally endemic, characterized by vomiting and 
diarrhoea, cramps, heart failure, and rapid collapse. 

Cholera morbus has been known from the most remote antiquity. 
It was this affection which received the name cholera. The cause 
of the disease has been ascribed to excessive heat, to exposure to cold, 
to bad diet, to unripe fruit, fermenting and decomposing food and 
drink, artificial feeding of infants, to contaminated drinking-water, 
etc. The disease is evidently due to the absorption of some toxine 
from the intestinal canal, though no particular micro-organism has 
yet been distinctly isolated from the myriad bacteria of the intes- 
tinal canal as its cause. 

Symptoms. — The disease begins with pains in the stomach and 
bowels, severe colic with flatulence and rumbling, and is announced 
in the course of an hour or two with vomiting at first of the contents 
of the stomach stained with bile (bilious vomiting), and later dis- 
charges from the bowels, copious, offensive, also stained with bile, 
which are hurried along under rapid peristalsis. It usually ceases 
with these signs in the course of the same day, but may persist in the 
enfeebled or aged, more especially in childhood, to show the alarm- 
ing signs of true cholera, rice-water discharges, cramps, hoarseness 
of voice, heart failure, anuria, cyanosis, and asphyxia or collapse. 
Convulsions and comatose states are common in children. 

Diagnosis. — In severe form the disease may be differentiated 
from true cholera only by the detection of the cholera spirillum as 
established by its conduct on culture soils. 

The prognosis is favorable. Most patients recover quickly under 
appropriate treatment. On account of damage to the heart an attack 
is dangerous in advanced life, and aged people occasionally succumb 
to the disease. The outlook is very grave in childhood under arti- 
ficial feeding, where the form of the disease is more subacute, but 
becomes immediately favorable under recourse to a good wet-nurse. 

The treatment consists in the prompt use of opium, as indicated 
under Asiatic cholera. Where the suffering is not too extreme for 
delay with this drug, recovery is hastened by first washing out the 
stomach with copious draughts of hot water, or preferably with the 
stomach tube. Irrigation of the bowel with solutions of alum water, 
four or five pints, half a drachm to the pint, assist in the same way. 
Where pain is severe an adult should receive at once a subcutaneous 
injection of morphia gr. -J— J. .Caution must be used with repetition 
of this use of morphia, as absorption is powerful under the drain of 
the discharges, and patients are easily narcotized. Cracked ice, and 
chloral gr. ij.-v. in peppermint water, will usually allay vomiting. 
The body must be kept warm with external heat, the heart's action 



CHOLERA. 345 

supported with alcohol, brandy, and analeptics, as already described. 
More protracted, obstinate (subacute) cases are best brought under 
control by astringent irrigations. The whole bowel is washed out 
with solutions of alum, tannin one per cent, or other astringent, as 
described in the treatment of dysentery. The stomach should be 
drenched with hot water. 



PART II. 
DISEASES OF ORGANS 



DISEASES OF THE 

ORGANS OF DIGESTION. 



CHAPTER I. 

DISEASES OF THE MOUTH, FAUCES, AND PHARYNX. 

Diseases of the mouth for the most part reveal themselves 
readily to inspection. Daylight is the best. Evidence is sometimes 
shown in the condition of the lips, which may be swollen and fis- 
sured, as in cases of eczema, scrofula (tuberculosis). Herpes about 
the lips may signify merely ephemeral catarrhal infections, or may 
indicate pneumonia, cerebro-spinal meningitis, etc., so that herpes 
has both diagnostic and prognostic significance. 

Cyanosis reveals itself usually first about the lips. A light-blu- 
ish tint catches the eye of the physician as an index of heart disease 
or impeded respiration (pneumonia). The same discolorations are 
evident on the inside of the mouth, especially about the region of the 
palate, where at times the light-yellowish tinge of icterus is first or 
is corroboratively observed. Certain drugs (antipyretics) give rise to 
a bluish coloration of the lips. 

Tumefactions which may be visible upon the outside of the face 
are best examined by palpation with one finger inside, the other out- 
side the mouth, whereby often inflammations of the gums, whether 
mere indurations or containing serum, blood, or pus, often in connec- 
tion with carious teeth, are observed. The mucous membrane may 
be hyperemia indented by the teeth, ulcerated, or covered more or 
less extensively with membrane or sloughs as indicative of various 
forms of stomatitis. 

The tongue may be swollen and indented by the teeth, or cut, ul- 
cerated, showing bleeding wounds along its edge or scars indicative 
of epileptic attacks. The enlargement of the tongue is often a ve- 
nous engorgement due to glossitis or to an extralingual infection. 
The most common cause of glossitis (stomatitis) is mercurial poi- 
soning. In this condition the gums also become swollen, tender, as 
the first evidence of the condition. Effort is made in treatment of 
various conditions by mercury to avoid stomatitis, so that the admin- 
istration of the drug should cease upon the first evidence of tender- 
ness, as the patient closes the jaws more forcibly, or with the first ap- 



350 DISEASES OF THE MOUTH, FAUCES, AND PHARYNX. 

pearance of increased saliva. The drug is most efficacious when the 
administration of it is continued up to the time when it (barely) 
touches the gums. It may still be administered (see treatment) with 
the simultaneous exhibition of chlorate of potash and frequent cleans- 
ing of the mouth. This continued administration is a great deside- 
ratum in many cases, notably in the treatment of dropsy of heart dis- 
ease, where no remedy can take the place of calomel. 

The recognition and treatment of affections of the teeth constitute 
the special department of dentistry, which has reached great perfec- 
tion in our day. It falls within the province of the physician to em- 
phasize the necessitj^ of cleanliness and care of the teeth, which care 
should be extended also to the first set in a child, that the permanent 
set may be perfect. Notches in the incisors are recognized as an evi- 
dence of impaired nutrition. Late . appearance, imperfect develop- 
ment, go along with rickets and syphilis. Semilunar excavation of 
the upper middle incisor, taken in connection with catarrh of the mid- 
dle ear and keratitis, constitute the triad (not so infallible as Hutch- 
inson claimed) in evidence of hereditary syphilis. 

Occlusions, retention cysts, calculi, are sometimes, though rarely, 
discovered in connection with the salivary ducts. The hard and soft 
palate present distinctive evidence of disease. The physician has here 
to differentiate between simple, catarrhal, diphtheritic, and specific 
processes. The palate is a favorite site of syphilis. There is ob- 
served at first intense hypersemia with swelling, which may not be 
separated from a simple catarrhal process. Later, however, distinct 
erosion of tissue occurs, whereby the soft palate is slit up often by 
the side of the uvula, or perforated to permit regurgitation of fluids 
through the nose — conditions often found associated with destructive 
lesion in the nose itself. The alee nasi may be alone or simultaneously 
invaded, with gradual progressive erosion and subsequent marked 
deformity. The septum of the nose is perforated or the bridge broken 
down. The sunken bridge of the nose constitutes almost infallible 
evidence of lues. The lesions in the throat distinguish themselves 
by their painless but progressively destructive character. They dis- 
tinguish themselves also by the rapidity of their disappearance and 
complete cure under appropriate treatment. In any case of doubt the 
patient should be subjected to this treatment, that the diagnosis may 
be established before irreparable deformity ensues. 

The mucous membrane which lines the mouth and covers the 
tongue is dense, resistant, and relatively impermeable, so that, not- 
withstanding the exposure of these organs to insult and injury, dis- 
ease of the mouth and tongue is rare. It is otherwise with the 
throat. The stomata of the tonsils, which permit the migration of 
leucocytes at all times (Stohr), readily admit pathogenic micro- 



STOMATITIS. 351 

organisms. The absorptive (lymphatic) system of vessels is pecu- 
liarly rich in the throat. 

STOMATITIS. 

Stomatitis (aro/xa, the mouth) shows itself in a number of forms, 
catarrhal, ulcerative, gangrenous, and special affections have been 
set apart, as aphtha, thrush, and noma. 

Micro-organisms have been found in all forms of sore mouth. In 
certain cases— thrush, actinomycosis — genetic relationship has been 
established. In other cases — forms of stomatitis, aphtha — micro- 
organisms find entrance only when normal resistance has been over- 
come or epithelial barrier broken by lack of nutrition, long macera- 
tion, chemical irritation (mercury), etc. 

Stomatitis catarrhalis is 
produced by mechanical, chemi- 
cal, or thermic irritant, as in in- 
fants by maceration from long 
suckling of empty breasts, or by 
an even worse habit, the use of 
sugar teats or bags, etc. ; in adults 
more especially by strong tobacco 
and alcohol, hot, highlv spiced or 

. n .. ■, . -i • n , ,i Fig. 172.— Mould fungi, etc., from mouth: 

acid tOOd Or drink, Caries Ol teeth, a< flat epithelium; b, granules of saliva: c. fat; 

by Certain infectious diseases, d > leucocytes: e, spirochetes buccalis;/. com- 

-, i j_ n n naa bacilli of mouth ; g, leptothrix buccalis; 

measles, scarlet fever, small-pox, ^ L fc? var ious fungi, 
typhoid fever, diphtheria ; in con- 
nection especially with syphilis, sometimes with cancer, much more 
rarely with tuberculosis. 

Symptoms. — Patients complain of dryness, burning, and posi- 
tive pain. Infants at the breast whimper and cry with distress, and 
sutler actual inanition from inability to take or retain the breast. 
The taste is lost in adults, sometimes the breath is foul, more 
rarely salivation is profuse. 

The mouth shows on inspection spots and surfaces of redness and 
swelling. The tongue, more or less heavily coated, is swollen, 
its edges often indented by the teeth. The gums may be swollen, 
spongy, tender, bleeding, or blue. 

Stomatitis ulcerosa is distinguished by deeper lesions — viz., 
by necrosis and destruction of tissue, especially in the vicinity of 
the incisor and canine teeth of the lower jaw. The swollen, spongy 
gums bleed spontaneously or on the slightest touch, and epithelium 
breaks down later to leave an ulcer covered with a gray slough. 
The process may involve also other parts — the mouth, the lips, 
cheeks, border of the tongue, etc. The disease was more frequent in 




352 APHTHA. 

old times under the abuse of mercury, but is now more frequent 
with disuse of the drug in connection with the lesions of syphilis. 
Bad cases may be associated with inflammation of neighboring 
lymph glands, may show oedema, gangrene, and sepsis, or, after ex- 
tensive sloughing of the gums, result in periostitis, caries, and se- 
questration of bone. 

•The disease is most frequent in childhood, and sometimes assumes, 
under conditions of crowd-poisoning in camps, jails, ships, the pro- 
portions of an epidemic. 

Ulcerative stomatitis begins almost suddenly with pain, fetor, 
and salivation. The excessive fetor is characteristic. The gums 
about the ulcer grow tender and bleed. These symptoms, with the 
appearance and situation of the lesion, make the diagnosis plain. 
The prognosis is for the most part favorable. Abstention from to- 
bacco, alcohol, or other bad habits, from mercury or other drugs, 
quickly stops a toxic stomatitis. 

Thrush and actinomycosis have been already described. 

APHTHA. 

Aphtha (acpdai, an too, to inflame). — An acute infection of the 
mucous membrane of the mouth in children, attended or preceded by 
fever and general distress, caused probably by a staphylococcus 
(citreus and flavus, E. Frankel ; vide Foot and Mouth Disease), 
characterized by the formation of small pin-head or larger scattered 
superficial grayish spots bordered ivith a bright-red line. The 
disease occurs most frequently in the second year of life, and is rare 
after the age of six. It is especially frequent in orphan asylums, 
tenement houses, etc., where it may assume in its successive, not 
simultaneous, attack of the inmates something of the proportions of 
an endemic. It is entirely independent of, though often coincident 
with, dentition. 

The prodromal fever is sometimes high, and the cause of it is dis- 
covered often only by that general inspection which leads to the ex- 
amination of the whole body, including the throat. 

The mucosa of the mouth shows more or less diffuse redness ; the 
glands about the neck may be swollen. The eruption — ten to twenty 
spots in all— appears in the course of a day or two anywhere in the 
mouth, but with especial predilection for the tip and borders of the 
tongue, sides of the frenum linguae, gums, cheeks, lips, and palate. 
More rarely the characteristic spots may be seen upon the posterior 
wall of the pharynx and tonsils. The eruption is a fibrinous exuda- 
tion with subsequent necrosis of epithelium. Denudation of the epi- 
thelium makes the mouth sensitive and sore; salivation may be 
profuse, and nutrition may be impaired through difficulty (pain) in 



APHTHA. 353 

dividual spots heal from the periphery by gradual con- 
• of the red border to the centre. Each spot lasts five to six 
e whole eruption with its successive crops ten to twelve days, 
:st slight depressions of lighter color, never any real 
bh final complete restoration of tissue. 
ignosi ?. — Aphtha is distinguished from traumatic lesions of 
Louth, from sharp teeth, pertussis, erosions, etc., from burns, 
yphilitic processes, etc. , besides by the site of aphtha, 
• it the eruption is scattered, isolated, circumscribed, and 
1 a bright-red line. So also are separated forms of 
..._-natii 5, __phtha never shows real ulcers and is not of itself at- 
tended with fetor oris — facts which distinguish it from ulcerative 
stomatitis. Thrush is a separable curd or deposit, often of great ex- 
tent, on the surface, and hence easily separable from aphtha. Since 
the special form of aphtha known as Bednar's aphtha, which consists 
of erosions or ulceration on each side of the raphe of the hard palate 
close to the alveolar border, has been demonstrated to be due to in- 
jury inflicted by the fingers and cloths in the act of cleaning the 
mouth (Baumm, Epstein), and not to sucking lesions or to syphilis 
as formerly 'elievedj the condition has lost all pathological interest. 
pmark applies also to the miliary eruption, ' ' epithelial 
rein), which shows itself directly and only in the line 
as yellowish, round, prominent bodies of the size of a 
d which has been demonstrated to be normal growths 
slefts. The slight ulcers which result from accidental 
surface speedily heal. 

phtha is obviated by avoiding the roof of the mouth 
vashing out the mouth. 

. — Most cases of sore mouth in infancy can be pre- 
ted by 'loanliness of breasts, artificial nipples, feeding bottles, 
etc. Inspection of dairies and occasional testing of milk itself by- 
competent sanitary officers best secure purhry for this staple food. 
Attention to the first teeth, especially to carious teeth, the early use 
of the brush — these are points of the first order in prophylaxis. 
Mouth washes of borax, a teaspoonful to a glass of water, or boric 
acid with glycerin and water, secure asepsis as well as antisepsis. 
Spongy gums are best treated with daily brushing or pencilling with 
tincture of myrrh or of rhubarb, the root of which chewed is also an 
effective and, to many, pleasant astringent. The standard remedies 
in the treatment of all forms of sore mouth are nitrate of silver and 
chlorate of potash. Ulcers or abrasions of stomatitis are lightly 
touched with the stick once a day or every other day. The albu- 
minate of silver which thus coats the surface protects it from further 
insult or injury, and the healing process goes on beneath. The chlo- 
23 



354 APHTHA. 

rate of potash is best given internally, that it may come in more con- 
stant contact with the parts in its continuous elimination by the saliva. 
A teaspoonf ul of a saturated solution in peppermint water every two 
hours is maximum dosage. The dose of the chlorate should not ex- 
ceed one or two drachms per day to an adult. The permanganate 
of potash ranks high as a mouth wash or local application with a 
cameFs-hair brush in the proportion of 1 : 100. It is especially use- 
ful in ulcerative forms with excessive fetor. Thymol gr. xv. , alco- 
hol, aqua aa \ ij., makes a good purifying mouth wash. Mercurial 
stomatitis is best treated by thorough cleansing with a cotton- 
wrapped sound. The cotton is to be carried along the edge of the 
gums and inserted between the teeth, especially the back teeth, where 
the process, as determined by gravity in the night, commences. 
Hereupon the gums and spaces between the teeth are to be treated 
with a concentrated solution of chromic acid. In sensitive subjects 
the treatment may be preceded by an application of cocaine, ten per 
cent. Feibes, who first used this treatment, recommends alsc 
powder, especially under mercurial treatment : 

5 Calcii carbonatis prsecipitati, 

Lapidis pumicis subtile pulveris, 

Potassii chloratis, 

Cinchonae rubrae corticis pulveris aa 

Rhei radicis pulveris 

Saponis puri 

Olei menthae piperitae 

M. Ft. pulveres subtiles terendo. 

As a gargle : 

5 Solutionis alumini acetatis 10.0 : 200.0 

Aquae florium aurantii 200.0 

M. S. One tablespoonful in a glass of water as a gargle every half -hour. 

Noma, a gangrene of the cheek, attended with the most profound 
destruction and horrible deformity, is fortunately a very rare (22 cases 
in 8,286 patients, Woronichin) condition. It occurs mostly between 
the ages of two and seven, next among soldiers. It is found, as a rule, 
only under the most degraded surroundings, usually in the course of 
one of the infections, chiefly measles, typhoid fever, small-pox, some- 
times whooping cough, and syphilis and rickets, and in connec- 
tion with thrombotic occlusion of vessels. It is fatal by sepsis in 
three-fourths of all cases. It must be attacked with carbolic acid, 
concentrated solutions, with corrosive sublimate, or with actual fire, 
PaquehVs thermo-cautery, ferrum candens, galvano- caustic wire. 

The coat of the tongue has less significance in our day. A 
healthy tongue is always more or less coated in its posterior third. 
The coat is, with epithelial debris, a mass of micro-organisms, of 



APHTHA. 



355 



which the mouth is a reservoir. A perfectly clean condition from 
front to rear is not a sign of health. The coat of the tongue is an evi- 



? - 




Fig. 173.— The tongue coated white, moist. Section from case of granular kidney (Dickinson). 

dence rather of the condition of its mucous membrane, with reference 
more particularly to exfoliation and detachment of foreign matter. 






Fig. 174.— The tongue denuded, red, and dry (raw-beef tongue). Section from case of peri, 
tonitis (Dickinson). 

A healthy tongue sheds its coat so continuously as to prevent accu- 
mulation. Interruption? of the circulation which impair its nutri- 



356 ANGINA. 

tion, in infectious diseases, for instance, or in any cachexia, interfere 
with this process and lead to a coated tongue. The coat of the tongue 
is therefore not so much an indication of the condition of the sto- 
mach as is commonly believed. Nevertheless the condition of the 
tongue is an index of disease. 

The tongue shows a difference also in dryness. Ordinarily it is/ 
moist. The extraordinary pliability of the tongue is due largely tc! 
its humidity. Where the nose is occluded, as by catarrh, polypi, etc., 
and breathing takes place by the mouth, the tongue becomes dry, its 
movements inhibited, even its protrusion from the mouth difficult or 
impossible. When the uncoated tongue becomes dry it assumes a 
glazed and horny appearance. The coated tongue, dry, shows a 
brown or blackish crust, which leads to the formation of crusts and 
fissures, whence blood may exude to become inspissated, to make of 
the organ an indurated, immobile mass. A peculiar " black tongue " 
is caused by certain fungi. 

ANGINA. 

Angina (ayxoo, to choke). — A term applied to all kinds of affections 
of the fauces, pharynx, and throat attended with pain, dysphagia, 
and dyspnoea, but more strictly limited at the present time to affec- 
tions of the fauces and tonsils. Aside from the sore throat produced 
by specific diseases — scarlet fever, diphtheria, syphilis, tuberculosis, 
scurvy, etc. — forms of angina are described of the fauces as catarrhal, 
rheumatic, herpetic; of the tonsils as lacunar, follicular, phlegmonous; 
of the whole throat as septic, gangrenous, erysipelatous, etc. A spe- 
cial form which emanates from the mouth, salivary ducts and glands, 
and involves the whole mass of tissue composing the floor of the 
mouth and upper throat, is set apart and distinguished as angina 
Ludovici. Retropharyngeal abscess is also often erroneously in- 
cluded under the term angina. 

The tonsils are the seat of frequent disease. Simple catarrhal 
inflammation expends itself upon the surface of the tonsils or extends 
to involve the soft parts in their immediate vicinity. Pain in the 
pharynx, tenderness to pressure, more or less difficulty with degluti- 
tion, are signs of this affection, which shows itself by increased swell- 
ing and redness on inspection. A special variety of tonsillitis is shown 
in the so-called follicular form, whereby the natural crypts or follicles 
are enlarged and contain caseous masses which, when removed, as by 
the finger nail, spoon handle, or point of the knife, emit upon pres- 
sure of the caseous mass an excessively fetid odor. In situ they often 
cause inflammation about them. They sometimes stick like a pin or 
a knife, unpleasant sensations which disappear with their removal. 
More extensive or deep-seated inflammation involving the structure 






ANGINA. 357 

of the tonsil is shown in the suppurative or phlegmonous form. In 
these cases the tonsil enlarges to twice or thrice its natural size. It 
protrudes to partially block the throat, and shows itself as a hard 
swelling upon the outside of the neck. Inspection reveals this glo- 
bular mass, which is more distinctly outlined by palpation between 
two fingers, one external, the other internal; and points of suppura- 
tion may be seen upon the surface of the tonsil, more especially in its 
posterior inferior region, or may be felt as a deep-seated fluctuation. 
Rupture which occurs naturally to discharge its contents, or incision 
which is made as soon as the condition is detected, cures the disease. 
More protracted are the cases of hypertrophy of the tonsils. Re- 
peated attacks of tonsillitis themselves leave the tonsils large. Life 
in a contaminated atmosphere, with its continual insults and more or 
less continual absorption of infected matter, eventually leads to perma- 
nent enlargement of the tonsils. Many children are born with large 



\ 
\ 



4 \ 




Fig. 175. Fig. 176. 

Fig. 175.— Pharyngo-nasal catarrh. Physiognomy before removal of adenoid tissue (Buck). 
Fig. 176.— Pharyngo-nasal catarrh. Physiognomy after removal of adenoid tissue (Buck). 

tonsils, or seem to acquire the condition early — not the result neces- 
sarily of scrofula (tuberculosis), but as the result of the absorption of 
other or any poisons in the mouth into these first outlying lymphatic 
glands (Hodenpyl). In these cases the tonsils are often found so 
large as to nearly or even quite touch each other, so that a slight 
additional inflammation brings them together or largely occludes 
the fauces. Children who live in an atmosphere of infection, more 
especially by the streptococcus, or of tuberculosis or of the various 
exanthemata, for any length of time, become subjects of enlarged 
tonsils. 

The condition seems in all cases to result from an absorption from 
the mouth and throat, and not from blood poisoning. 

Chronic hypertrophy may oppress the circumjacent structures in 
the same way as in a case of quinsy. Thus there is often disturb- 



358 ANGINA. 

ance of hearing from compression of the Eustachian tubes, or more 
especially from invasion of these tubes from the same infectious 
process. So, too, the nares may be blocked. The sense of smell is 
abolished; the child becomes a mouth-breather. The physiognomy 
then changes. The countenance is listless, the expression drooping 
and vacant, the special senses lose their keenness of perception. In 
adults the condition is wont to be associated with more or less melan- 
choly. This hypochondriasis leads to frequent change of physicians, 
to the use of various nostrums, proprietary and patent medicines. 
In fact, pharyngeal or pharyngo-nasal catarrh, with which this con- 
dition is associated, is a special field for quackery, and from its mental 
associations has developed a specialty even in regular medicine. Ex- 
cessive refinement has been reached in the study of these cases of 
pharyngeal catarrh. Surfaces from which the upper layer of the 
mucous membrane have been denuded appear glazed, shining, and 
dry. Thicker mucosae show a more granulated or gelatinous appear- 
ance. Follicular affections show pinhead granules, sometimes pain- 
ful, in the pharyngeal wall, on the palate, especially on the surface of 
the tonsils, where they may be seen as whitish masses from the size 
of a pinhead to a pea, which may be expressed by the finger nail 
or the handle Or point of the scalpel, to liberate caseous particles of 
excessively offensive odor. 

Another cause of occlusion, especially at the vault of the pharynx, 
is the formation of adenoid tissue, succulent masses of low vitality 
rich in lymph cells, rapid in growth, which spring from the posterior 
wall of the palate or vault of the pharynx, to at times occlude the 
posterior nares, alter the voice, and interfere with respiration. These 
are the cases in which are noticed the alterations of voice which pro- 
duce the nasal twang. The change is noticed more especially with 
the articulation of certain letters, m, n, ng, to which are given a dead 
expression characteristic of the condition, on account of occlusion 
of the resonating cavities in and about the nose. 

The diagnosis of the various forms of angina is made by simple 
inspection, by examination with the laryngoscopic and pharyngeal 
(rhinoscope) mirror. Palpation recognizes enlargement of lymphatic 
glands in the neck. 

The treatment of acute angina consists in rest in a pure, warm 
atmosphere, and relief of pain by external application of heat, hot- 
water, flannels, gargles of hot water, applications of cocaine four per- 
cent solutions, and the internal use of salicylic acid or salipyrin: 

$ Salipyrin.. 3 i.-ij. 

Glycerinse § i. 

->y rupi Hiirantii corticis § ss. 

quae ... . . . I iiss. 

M. 8. Dessertspoonful to tablespoonf ul every three or four hours. 



ANGINA. 359 

One whole dose gr. x., or several broken doses of Dover's powder 
gr. iij., quickly relieve tension and pain. Inhalations of steam im- 
pregnated with carbonate of soda help also to relax tension and 
relieve pain. The lapse of a little time must be awaited with some 
patience in the resolution of an acute angina. 

The chronic hypertrophies and catarrhs are treated best by as- 
tringent applications of alum and iron, ferric alum, gargles or sprays 
of the same materials, especially by the nitrate of silver of varying 
strength ; more obstinate cases by parenchymatous injections into 
the tonsil, as of iodine, etc , applications to the surface of stronger 
caustics of London and Vienna paste and caustic potash. By far the 
most effective remedy in the treatment of these conditions, whether 
of hypertrophied tonsils, exuberant mucosae, or adenoid tissue, is 
the gal vano -caustic wire. Either the hypertrophied tonsil is sur- 
rounded by a loop, which is gradually tightened, or by means of the 
knife, more particularly the guillotine, a slice of the tonsil is ab- 
stracted, whereupon the mass will usually undergo atrophy. The 
loop is also introduced into the interior meatus to destroy hyperplas- 
tic tissue in the nose, or, by means of the finger in the mouth, may 
be carried up about any adenoid tissue in the vault of the pharynx 
to successfully remove it. Or the galvano-caustic platinum spatula 
or plate may be brought to bear upon the mass in situ to effect, in 
the course of several sessions, its entire destruction. 

The (Esophagus is seldom the seat of disease. Constituting, as 
it does, the avenue of entrance of all food and drink, and subjected to 
every possible variety of insult, it is surprising that it is not more often 
affected. The reason of the exemption lies probably in the rapidity 
of transit through the tube. The diseased condition most commonly 
encountered is the nervous contraction known as globus hystericus. 
This condition is supposed to result from an approximation by circu- 
lar contraction of the oesophageal walls, and is one of the common 
expressions of hysteria. It is found, therefore, more frequently in 
hysterical patients, young females ' especially, in connection with 
emotional disturbance. It reveals itself often by the fact that more 
obstacle is offered to the deglutition of fluids than solids. Solids are 
swallowed easily, fluids are regurgitated. The condition is usually 
readily recognized by the passage of the stomach tube. Gentle and 
persistent effort will always overcome a spasmodic constriction. 

Contraction of the lumen of the tube from other cause is the con- 
dition next most frequent. This contraction may be due to outside 
cause, a s a goitre, an aneurism, a tumor of the neck or chest ; or it 
may be due to intrinsic cause, as to the cicatrization of an ulcer. It 
is most frequently due to carcinoma. Inasmuch as the oesophagus 
cannot be inspected or subjected to palpation, and inasmuch as oeso- 



360 ANGINA. 

phagoscopy is as yet entirely unsatisfactory, examination may be 
aided by auscultation. Auscultation along the left side of the ver- 
tebral column reveals in the act of deglutition a peculiar gurgling 
sound, which has been likened to that which is emitted by the fluid 
ejected from a syringe ; while auscultation in the region of the ster- 
num discloses a peculiar pressure sound several minutes later than 
the first sound. This second sound in the presence of obstruction 
may be absent altogether. Much more reliance is to be placed upon 
examination of the oesophagus with the stomach tube or oesophageal 
sound. In all cases examination should be made with the ordinary 
soft stomach tube first. It is impossible to do damage with this 
tube. The instrument is anointed with glycerin rather than with 
olive oil or vaselin, seized with the finger and thumb of the right 
hand, after the manner of holding a pen, while the left hand is in- 
troduced into the mouth of the patient seated in front of the physi- 
cian, and as the end of the tube reaches the posterior pharyngeal 
wall the fingers of the left hand are depressed to turn the tube into 
the oesophagus. Once past the larynx, the tube glides readily to the 
stomach. The obstruction which is encountered opposite the larynx 
is natural. There should be encountered no obstruction in the fur- 
ther course of the tube. Should this soft tube fail to pass, recourse 
may then be had to the English sound of solid rubber or waxed silk, 
a thick, continuous rod, smaller at the end, which terminates in a 
bulbous enlargement. This tube may be rendered slightly softer by 
immersion in hot water, and is with much more ease introduced to 
the stomach. Finally, the whalebone sound, with its series of olive- 
shaped metal tips, may be substituted to push down the foreign body 
or to dilate a commencing stricture. Stricture from an ulcer usually 
results from an ingestion of an acrid poison, mineral acid, etc., and 
is encountered in the upper part of the oesophagus. Peptic ulcers 
are excessively rare in the oesophagus. 

Cancer of the oesophagus is a not infrequent disease ; it is the 
most frequent organic disease of the oesophagus. It is encountered 
for the most part after the middle period of life, in individuals who 
show more or less cancerous cachexia and complain of pain with 
difficulty of deglutition or regurgitation of solid food, which ac- 
cumulates in the pouch above the stricture. 

The seat of cancer is in the lower half of the oesophagus, more 
especially about the region of the cardiac orifice. It shows itself at 
first, as a rule, as a girdle-like stricture, to permit often the passage 
of the smaller sounds ; often as an impermeable mass with a pouch 
above it, in which the softer tube rolls itself up to give the impres- 
sion at times of penetration into the stomach. The treatment of can- 



ANGINA. 361 

€er of the oesophagus impenetrable by the tube or sound does not 
differ from that of cancer of the pylorus. 

Angina Ludovici starts from the submaxillary gland, whose 
tissue is invaded through its ducts by pyogenic micro-organisms. It 
occurs in connection with the infections, but arises oftener of itself. 
It distinguishes itself by the extent of its range and the severity of 
its inflammation. The region of the floor of the mouth, the whole 
lower jaw, sometimes the whole throat, forms a vast mass of board- 
like hardness. All the functions of the mouth are crippled. Com- 
pression of the great vessels in the neck may develop cyanosis of the 
face, insomnia, sometimes confusion of ideas and extreme general 
distress. With suppuration, which is often prefaced by surface 
oedema, sepsis may ensue, with chills, sweats, icterus, diarrhoea, 
petechiae, joint affection, and other signs of streptococcus infection. 

The treatment consists in applications of heat and moisture, free 
incision, with subsequent irrigation and disinfection of the cavity 
left. 

Retropharyngeal abscess results from caries of the cervical 
vertebrae (tuberculosis), or, oftener, infection of lymph glands at the 
back of the throat. Infection is carried to the glands in front of the 
second and third cervical vertebrae from the nose and throat in the 
natural course of the circulation ; hence the connection between this 
abscess and diphtheria, scarlet fever, and erysipelas is easily under- 
stood. The abscess arises, however, for the most part independently 
of these diseases, as it occurs chiefly in childhood in the first year of 
life. It is rare after the age of five; in fact, the condition itself is 
quite rare, but is of importance from the fact that it is often overlooked, 
a negligence which has been punished with fatal results. A swelling 
in the back wall of the small throat of an infant blocks the throat, the 
posterior nose, the Eustachian tubes, and may infringe upon or pro- 
duce oedema of the larynx. Rupture of the abscess, especially spon- 
taneous rupture, may inundate the t larynx, and, more likely in the 
night, drown the patient, or pus may burrow to the mediastinum and 
break its way into the pleura or pericardium. More rare are the 
cases in which the discharge finds vent in the parotid gland or on the 
surface at the angle of the jaw. 

The abscess may develop rapidly in the course of a few days, or 
slowly in the course of weeks or months. Acute cases are attended 
with pain, dysphagia with regurgitation, and dyspnoea with snoring 
respiration. Hoarseness of voice (cry), signs of stenosis, cyanosis, 
swelling of the cervical veins, retraction of the chest, give proof of 
pressure upon the larynx. All the signs are easier under decubitus 
with the head retracted upon the spine, and are aggravated with 
flexion of the head upon the body. Inspection reveals a tumor, tough, 



362 ANGINA. 

elastic, or fluctuating to touch. Aspiration may disclose the contents 
and character of the growth. 

The prognosis is favorable if the disease be recognized early, and 
the abscess may be evacuated without danger to the larynx. 

The treatment consists in the evacuation of the abscess, gradu- 
ally if necessary in protection of the larynx, by means of an aspira- 
tor. The knife, wrapped nearly to the edge, must be used with 
caution to avoid wounding important vessels. 



CHAPTER II. 

DISEASES OF THE STOMACH. 
GASTRIC CATARRH. 

An affection of the mucous membrane and musculature of the 
stomach, acute and chronic, characterized by indigestion, defective 
secretion of gastric juice, excessive secretion of mucus, pain, nausea, 
vomiting, constipation, depression of spirits, atrophy of the mucosa, 
and marasmus. 

Gastric catarrh was formerly known and described under the 
term gastritis. Gastritis is objectionable. It fails to localize the 
affection. Gastritis is used in our day to express a more intense or 
extensive inflammation of the stomach, that which results, for in- 
stance, from the ingestion of poisons, mineral acids, etc., which 
corrode and perforate the various coats of the stomach. Catarrh 
limits the disease to the mucous membrane. This term is also not 
unobjectionable, for it is especially a gastric catarrh which does not 
remain confined to the mucous membrane, but extends to and in- 
volves, at least produces paresis in, the muscular coat. On the other 
hand, as an advantage, the term catarrh implies an inflammation 
likewise of the various glands, mucous and peptic, of the stomach ; 
for the stomach mucosa is not to be regarded as a mere surface 
membrane, but as an organ made up of closely apposed, deeply in- 
voluted glands. Ewald appropriately calls the disease a gastritis 
glandularis. Dyspepsia is only a' symptom. Catarrh is every- 
where a provisional term. Under catarrh is embraced that group of 
affections which cannot be accounted for by any specific process, 
ulcer, cancer, etc. 

Etiology. — Gastric catarrh may be the expression of irritant 
ingesta, of an insult offered to the stomach in the food or drink. It 
results often from faulty habits of life, particularly with regard to 
food, quality, quantity, preparation, time of taking, etc. The action 
of the stomach is also strongly under nervous influence, so that 
catarrh may result from neuroses. A 'fruitful source of catarrh in 
our country is worry, business worry. Gastric catarrh is the result 
of causes both intrinsic and extrinsic. No mucous membrane is more 



364 GASTRIC CATARRH. 

sensitive than that of the stomach. Many of the worst cases of gas- 
tric catarrh result from diseases of other organs, and the physician 
in the presence of gastric catarrh, more especially chronic gastric 
catarrh, must first of all eliminate disease of other organs. Accord- 
ing to the intensity of the symptoms, or more especially the duration, 
catarrh is divided into the two forms, acute and chronic. 

Acute catarrh finds its most frequent expression in infancy, and is 
the direct result of an offence, irritation, of the mucous membrane by 
improper food. The human race would long since have been re- 
duced to very limited numbers were it not for the fact that the food 
of infancy is for the most part furnished fresh. Infants fed at the 
breast of healthy mothers seldom suffer acute catarrh. Overfeeding 
is attended with overflow; easy, natural vomiting, more in the way of 
regurgitation, relieves a distended stomach. How slight an effort is 
required to secure this relief is observed in the frequent vomiting 
which occurs in a well-fed child after the lightest pressure upon the 
stomach. 

Gastric catarrh, more properly gastro-intestinal catarrh, is the 
most frequent and most fatal disease in childhood, especially in hot 
weather. The food of childhood, milk, from any outside source, is 
most prone to undergo decomposition. The poor have no ice chests 
and no provision for the preservation of milk. Consequently the 
poor not fed at the fountain of nature succumb in the heat of sum- 
mer. 

Acute gastric catarrh in adults is the result more frequently of 
insult to the stomach by improper or injudicious drinks. Not at all 
infrequently the fault lies with the drinking-water itself, which is 
contaminated by the discharges of disease, typhoid fever, dysentery, 
etc. Gastric and gastro-intestinal catarrh may be the means in 
these cases of eliminating causes of disease, which otherwise find 
lodgment to reproduce the disease itself. Individuals have been 
rescued from trichinosis by the copious vomiting which has dis- 
charged the infected food. Crude beer, sophisticated wines, drugged 
whiskey and brandy, etc. , inflame the stomach to produce acute gas- 
tric catarrh. Improperly cooked foods may act at any time in this 
way. 

Gastric catarrh belongs to all the acute infectious diseases. An- 
orexia, nausea, sometimes vomiting, announce the onset of these affec- 
tions. An acute indigestion results at times from exposure to cold, 
as also from nervous emotions. 

Chronic catarrh is for the most part an expression of an outside 
disease. At the head of this list of diseases stands tuberculosis. 
Many cases of tuberculosis are marked by a long-continued and 
obstinate dyspepsia. Gastric catarrh may exist in these cases for 



GASTRIC CATARRH. 365 

months without suspicion of the existence of tuberculosis. It is plain 
to see that treatment addressed in this case to the stomach itself may 
bring little or no relief, wherea.s the condition may be made to dis- 
appear often promptly, sometimes permanently, by the recognition 
of its cause. B right's disease is a fruitful factor of gastric catarrh. 
The lack of appetite and digestion contributes largely to the progres- 
sive degradation of physical and mental tone in these cases. The 
gastric catarrh is the direct effect of some toxic matter circulating in 
the blood, which matter the kidneys fail to eliminate. These cases 
are singularly obstinate, and yield only, if at all, by reference or ad- 
dress to the cause of the condition. Disturbance in the portal circu- 
lation, disease of the liver (cirrhosis), soon brings about a gastric 
catarrh. Constant reflux of bile, by neutralizing the acidity of the 
gastric juice, begets the changes of catarrh. Disease of the uterus 
or ovaries is a not infrequent cause of gastric catarrh. Dyspepsia 
may be the first sign of carcinoma or salpingitis. Prostatitis is the 
analogue in the other sex. 

Gastric catarrh must be always carefully dissociated from ulcer 
and cancer of the stomach itself. This differentiation is often a 
nice problem in diagnosis. The fact is, both ulcer and cancer are, 
as a rule, associated with gastric catarrh. 

Pathology. — Chronic gastric catarrh is in its essence a parenchy- 
matous inflammation which results in a transformation of the proto- 
plasm of the gland cells into mucus, with final atrophy of the cells 
and glands. 

Symptoms. — Acute gastric catarrh announces itself with pain, 
more or less severe, in the region of the epigastrium. The pain is 
attended at times with sinking sensations, with actual vertigo. 
There is a vertigo a stomacho keso, which is often quickly relieved 
by the administration of a few grains of chloral to obtund the sensi- 
tiveness of the stomach nerves. Vomiting finally removes the acrid 
ingesta, to relieve the condition, at least for a time; and the true 
treatment of this condition is to quickly empty the stomach of its 
contents by the use of hot water or by the administration of a laxa- 
tive, which may discharge the contents of the stomach into the intes- 
tine. 

Chronic gastric catarrh has an extensive symptomatology. The 
pain of the chronic condition is not so acute, but it is more constant, 
and not so strictly dependent upon the taking of food, though it is 
always aggravated in this way. There is more or less tenderness 
to pressure over the region of the stomach in these cases. The sto- 
mach is frequently distended tvith gas, to show its enlarged outlines 
upon the surface to inspection or palpation. The distention is 
often so great as to impede respiration, or more frequently to inter- 



366 



GASTRIC CATARRH. 



fere with the action of the heart. Most attacks of simple palpita- 
tion of the heart are the expressions of an indigestion. Reflected 
acrid, burning pain in the course of the oesophagus is known as 
heartburn. Gas from the stomach escapes in eructations, which 
have often excessively fetid odor. 

The disease is associated for the most part with constipation, 
and, in consequence of the constipation, with haemorrhoids. Id 
consequence also of the defect in digestion and absorption of gases 
into the blood there is poisoning of the nervous system. The energy 
is reduced. The victim of gastric catarrh has a disgust for life. He 
can accomplish nothing. Many patients are melancholic. More are 
hypochondriacal. Nearly all hypochondriacs are dyspeptics, and 




Fig. 177. — Action of the digestive juices: A, muscle fibre from the stomach; B, starch gran- 
ules from the stomach; C, muscle fibre from the faeces (Wesener). 



this often notwithstanding the fact that they may be great eaters. 
Vomiting is a frequent symptom, of the contents of the stomach, of 
large quantities of tough, glairy mucus, of foul, acid, and other pro- 
ducts of fermentation, and of bile, along with masses of undigested 
food. Where the condition has existed for a long time, so that the 
submucous connective tissue has become hypertrophied, especially 
in the region of the pylorus, the stomach suffers distention to such 
extent as to simulate at times the gastrectasias of cancer, and to 
discharge thus by vomiting enormous quantities of accumulated 
matter. 

The diagnosis, which is discussed later in connection with or- 
ganic disease, is best established by means of the stomach tube. The 



GASTRIC CATARRH. 



367 



stomach tube gives information which surpasses in the exactness of 
its value that furnished by all other signs. The patient whose con- 
dition is to be investigated receives in the morn- 
ing a meal consisting of a plate of soup, a bis- 
cuit, and a piece of beef. This food should dis- 
appear from the stomach in six or seven hours, 
so that the tube, introduced into the stomach at 
this time, should withdraw nothing more than a 
little mucus. In gastric catarrh, however, resi- 
due, sometimes in large amount, of undigested 
food escapes through the tube and may be sub- 
mitted to further examination. It is observed 
then to what extent the muscular tissue is disin- 
tegrated and digested, how much the starch 
granules are eroded and destroyed, to what de- 
gree the fat globules are floated free. It is ob- 
served if fungi or bacteria be present in the mass, 
and the ejected matter is then subjected to chem- 
ical test. 

The information of most value in the studv 

P ,. n ,, , , . ,, ... „ Fig. 178. —The soft stom- 

or diseases or the stomach is the recognition of ach tube with openings at 
the presence, amount, or absence of free hydro- the end and side, and with 
chloric acid. The presence or amount of pepsin is reoeiving g ass unne ' 
secondary. It corresponds for the most part to the hydrochloric acid. 
It will be remembered that hydrochloric acid is not secreted in any 








Fig. 179— Partially digested matter from the stomach: a, muscle fibre; b, white blood cor- 
puscle; c, c, c, flat and cylindrical epithelium; d, starch corpuscles; e, fat globules; /, sarcina 
ventriculi ; g, yeast ferment ; h, i, cocci and bacilli (those near h were once found by Von Jakseh 
in a case of ileus, hence arising from the intestine) ; fc, fat needles, connective tissue ; I, vege- 
table cells (Von Jakseh). 



appreciable amount in an empty stomach. It begins to be secreted 
with the process of digestion, but is at first combined with the alka- 



368 GASTRIC CATARRH. 

lies in the food, and does not appear free until at the end of half or 
three-quarters of an hour. Now it shows itself in increasing abun- 
dance, to be present in greatest amount at the height of .digestion at 
the end of four or five hours. In catarrh of the stomach the amount 
of hydrochloric acid is limited. Hydrochloric acid is limited (sub- 
acidity) when present in less than 0.06 per cent; it is increased 
(superacidity) when present in more than 24 per cent. The acid 
may be discovered free or in connection with other acids, lactic acid, 
acetic acid, butyric acid, etc. , which hinder rather than help diges- 
tion. The excessively acid odor of vomited matter of gastric 
catarrh is no index of the amount of hydrochloric acid. Odor in 
these cases is due to acid fermentations, acetic, butyric, etc. — condi- 
tions which markedly interfere with digestion or are the expressions 
of impaired digestion. 

The detection of free hydrochloric acid becomes a matter of su- 
preme value when it is known that, as a rule, free hydrochloric acid 
is absent altogether in cancer, and present, though reduced in 
amount, in gastric catarrh. Free hydrochloric acid is absent or re- 
duced, not on account of any neutralization by products of cancer, 
but on account of disease of the mucous membrane. It is absent or 
reduced also in amyloid degeneration, atrophy from any cause, debi- 
litating disease, tuberculosis, Addison's disease, pernicious anaemia, 
all kinds of fever, etc. 

Numerous tests have been devised for the recognition of the 
presence and amount of free hydrochloric acid. A common test is 
made with methyl violet. Two test tubes are half-filled with trans- 
lucent solutions of methyl violet. To one are added a few drops of 
the filtered solution which escapes from the stomach tube. Free 
hydrochloric acid changes the violet to blue, and, if present in great 
amount, to green. Contrast is offered in the two tubes. The test is 
very simple, but is unfortunately not very reliable. The same dis- 
coloration results in the presence of much common salt, or the color 
may be concealed by products of digested albuminates, etc. 

A very convenient method is offered with a piece of filter paper 
soaked in a saturated solution of OO-tropseolin. A drop of the filtrate 
is let fall upon the paper, which is then heated in a watch glass In 
the presence of free hydrochloric acid the paper becomes brown and, 
as it dries, lilac. The value of this test consists in the fact that lactic 
acid does not produce this result. 

The best test is made with phloroglucin-vanillin — phloroglucin 
two parts, vanillin one part, absolute alcohol thirty parts (Gunzburg). 
To two or three drops of this fluid is added an equal amount of the 
filtrate in a watch glass or porcelain dish, which is then heated. In 
the presence of free hydrochloric acid the fluid assumes a deep red 



GASTRIC CATARRH. 369 

hue, in the absence of it a brown-red or brown. As the glass is 
heated and the acid fluid dries, streaks of crimson show themselves 
about the edge. The only fallacy that can occur in this test is that 
which will result after the ingestion of bad eggs, as it is invalidated 
by sulphuretted hydrogen. The phloroglucin-vanillin test will de- 
tect free hydrochloric acid in as small amount as 0.005 per 1,000. It 
is thus by far the most delicate and valuable test that can be em- 
ployed, and its execution requires but a few minutes. This test 
fluid, fresh, has an odor of vanilla and a golden-yellow color. It 
must be kept from the light, which turns it brown. 

Lactic acid is best disclosed by the test of Uffelmann. One or 
two drops of the solution of the chloride of iron added to about one 
hundred grammes of a two-per-cent solution of carbolic acid make a 
steel-blue mixture. To this fluid is added some of the filtered sto- 
mach juice. In the presence of lactic acid the solution becomes 
yellow, a yellowish-green. In the presence of hydrochloric acid it 
becomes clear like water. "Uffelmann's test will detect 0.01 per 1,000 
of lactic acid. 

Acetic and butyric acids are readily recognized by their odor, 
which may be additionally developed by mixing the stomach fluid 
with ether and evaporating the ether. Despite the searching inves- 
tigations of modern times (Boas, Sjoqvist), the physiological remains 
the best quantitative test for free hydrochloric acid. Cubes of albu- 
men (boiled egg) are digested in test tubes in an oven and compared 
with the results of healthy digestion. 

It is important to estimate the movement of the stomach, as 
movement constitutes an important factor in the digestive process. 

An ingenious attempt to discover the activity of the stomach was 
suggested by E wald, who administered salol in capsule and noted the 
time when the products of its decomposition should be discovered in 
the urine. Salol does not decompose in the stomach, but splits up 
into salicylic and carbolic acid in the intestine. Salicylic acid is rec- 
ognized in the urine by the violet color which results after the addi- 
tion of the chloride of iron. Ewald found the first positive reaction 
in health in a half to one hour after the drug had been taken ; but 
there was so much irregularity about the period of its recognition in 
disease as to make it practical!}- of little value. Pills of iodide of 
potash coated with keratin were then substituted, with the additional 
advantage that the absorption of the iodine could be determined by 
its appearance in the saliva. The patient expectorates upon starch 
paper every five minutes. The blue color is struck in health in 
fifteen to thirty minutes. A delay of one hour is evidence of disease. 
But this method also proved valueless in estimating motion, from the 
fact that the pills were sometimes dissolved in the stomach. 
24 



370 



GASTRIC CATARRH. 



Sufficient information for all practical purposes can be obtained 
with the use of the stomach tube. Introduction of the stomach tube 
is for the most part an easy matter. It implies a certain degree of 
confidence which the physician may be able to inspire so that suc- 
cess may attend the first efforts. As a rule, strange to sa}^, women 
succeed better than men. It not infrequently happens that the pa- 
tient may succeed in the first effort where the physician fails. All 
patients succeed after repeated effort, so that the introduction be- 
comes simple and easy. 




Fig. 180— Irrigation of the stomach. 



Fig. 181.— Discharge by siphonage. 



Treatment. — An acute indigestion is treated, as stated, by empty- 
ing the stomach of its contents. The most effective as well as the 
safest way to treat poisoning is to wash out the stomach. Patients 
who would have survived poisons are sometimes killed by so-called 
antidotes. Where the patient is conscious this relief may be secured 
by the ingestion of large quantities of hot water. The water should 
be drunk until it is rejected, without reference to quantity, and the 
operation should be repeated, having due regard to the exhaustion 
of the patient, until the fluid escapes clear. Resort must be had at 
times to the stomach tube in the presence of unconsciousness, un- 
willingness, etc., but great care must be exercised with all hard tubes 



CASTRIC CATARRH. 371 

to avoid perforation or inflammation of soft, tissue. It is best in all 
cases to use the soft tube, which may be forced into the stomach, if 
necessary, by the aid of a gag and a catheter introduced into the eye 
of the stomach tube with a blind end, and withdrawn after the oeso- 
phagus has been fairly entered. Warm water is then to be poured 
into the funnel until the stomach is full, when the tube is quickly de- 
pressed and the stomach emptied by siphonage. Where there is 
any delay in the flow it may be facilitated by squeezing the tube be- 
tween the thumb and fingers. The outside end of the tube may be 
inserted into a basin of water and slowly withdrawn toward the 
surface of the water, when the contents of the stomach soon begin to 
flow. Sometimes orifices in the tube become blocked by mixed par- 
ticles of food, etc., to require some manipulation. Patients soon learn 
to handle the tube themselves. Where the tube is used as a remedial 
measure the stomach should be washed out once a day, preferably at 
night, whereby often substantial sleep of a whole night is secured. 
Ordinary gastric catarrh, even though chronic, may be successfully 
treated without the tube by regulation of the diet and by drugs. 

The diet should commence with milk diluted one-half with im- 
ported Selters water. The milk may then be increased in strength, 
or it may be substituted by kumyss or egg largely diluted at first 
with hot water. In a day or two there may be added scraped or 
chopped beef with warm water and a little pepper and salt, mixed to 
the consistence of a thin mush; a tablespoonful of the meat mixture 
to be taken once or twice a day. In a few days more the patient may 
take the white meat of fish, sweetbreads, raw oysters, white meat of 
fowls, chopped steak, roast beef, and later bread, potatoes, and so on 
up to full diet, as described in detail later. 

Of drugs, far and away the best is hydrochloric acid, gtt. v.-x. in 
a wineglass of w^ater before meals. Next in value ranks arsenic, 
gtt. ii.-v. in a tablespoon of water after meals. The salicylates are 
especially adapted to cases in connection with gastralgia. The 
tincture of nux vomica gtt. x.-xx., solutions of strychnine gr. -^"tV? 
bitter tonics, Peruvian bark, the simple or compound tincture, give 
the stomach tone. The following formulae from Ewald are fine 
bitters : 

R Corticis condurango 25.0-30.0 

Macera per horas xii. cum aqua 300.0 

Digere lento calore ad colaturam. , 1 50.0 

Adde 

Acidi hydrochlorici diluti 5.0 

Syrupi zingiberis ad 200. 

M. S. Tablespoonful every three hours. 



372 ULCER, 

R Tincturae nucis vomicae 5.0 

Resorcin resublimati 10.0 

Tincturae gentianae 25.0 

Syrupi simplicis ad 200.0 

M. S. Tablespoonful every two or three Lours. 

Laxatives — Carlsbad salts, a teaspoonful in a wineglass of hot 
water before breakfast ; a compound rhubarb pill, one after each 
meal ; a pill of podophyllin, gr. J- |, at bedtime ; a tablet of cascara 
sagrada; a teaspoonful of a cascara mixture — suffice to relieve consti- 
pation. The antifermentative virtue of creosote has been remarked 
linder tuberculosis. 

ULCER. 

Ulcus pepticum, rotundum, perforans, etc. — A disease whose 
lesion is a small, round ulcer with tendency to haemorrhage and 
perforation ; characterized by pain, dyspepsia, hyperacidity of the 
gastric juice, vomiting, haematemesis, peritonitis, and liability of 
relapse. 

Ulcer of the stomach is a specific disease, quite different from an 
ulcer or a process of ulceration elsewhere. Ordinary ulceration may 
also affect the stomach, as the result, for instance, of the ingestion of 
irritants, mineral acids, or other poisons. Gastric ulcer distinguishes 
itself by its definite shape, size, location. It entails also certain com- 
plications and distinguishes itself by its tendency to relapse. Gastric 
ulcer is a frequent affection. It is a matter of surprise to those who 
are not familiar with the subject to learn that ulcer occurs or is found 
in five per cent of autopsies. The discovery of this condition so fre- 
quently" is not so much a proof of the fact that the disease is some- 
times latent, as of the fact that it is commonly confounded with gas- 
tric catarrh or is included under that vague, indefinite, and elastic 
symptom — dyspepsia. 

History. — The lesion of the" stomach in gastric ulcer is so gross 
that it could not fail to have been recognized by the earliest ob- 
servers. Galen mentions it and prescribes the diet which is still 
maintained as the main element of treatment. He says the food 
should be glutinous. Acid and acrid substances must be avoided. 
Wine may be taken, but not too hot or too cold. Gratius (1695) saw 
an ulcer which perforated the stomach. There was adhesion to the 
spleen, which prevented the escape of the contents of the stomach 
into the peritoneal cavity. Littre (1704) discovered the source of a 
fatal haemorrhage in a round ulcer of the stomach. Baillie (1793) 
spoke of the clean-cut edges, as if exsected by a knife. Abercrombie 
(1832) made important contributions to symptomatology. Cruveil- 
hier (1830) first distinguished the disease from cancer. Eokitansky 



ULCER. 373 

pointed out the frequency of its occurrence. Virehow (1865) found 
the cause of certain ulcers in blocks in the circulation. From the in- 
vestigation of several hundred cases Brinton was able to draw con- 
clusions as to the location and to illuminate many of the signs of the 
disease. Finally, Leube (1875) found valuable evidence regarding 
the diagnosis from the use of the stomach tube, and furnished the 
best instructions in the way of feeding these cases. 

Pathology. — Gastric ulcer is commonly known as the ulcus ro- 
tundum from its shape, and perforans from its tendency to erode 
the stomach walls. It is usually round or more or less elliptical 
and distinctly funnel-shaped, the orifice of the funnel being eccen- 
trically situated at the site of a gastric vessel. Ulcers vary greatly 
in size, from a ten-cent piece up to the largest ulcers, of more irregu- 
lar shape, resulting from the coalescence of two or more. Haber- 
shon described a case in which the ulcers or ulcerations reached 
from the pylorus nearly to the fundus. The ulcer is usually single. 
There may be a number in a single case. "Wollmann once found 
eight. Lange found so many that "'he gave up trying to count 
them.'* Ulcer of the stomach rarely coincides with ulcer of the 
duodenum or oesophagus. The edges of the ulcer, as stated, are 
clean-cut, as if removed by a punch (Rokitansky). Old ulcers. 
however 3 show indurations about their edges, to such extent at times 
as to have been taken for carcinomatous masses. It is the tendency 
of the gastric ulcer to perforate so that the base of the ulcer may 
involve only the mucosa, or the submucous connective tissue, or the 
muscular coat, or the peritoneal coat, which in turn may be perfo- 
rated to permit the escape of the contents of the stomach. Xot in- 
frequently such accident is prevented by agglutinative inflammation 
with adhesion between the stomach and contiguous viscus, liver, 
spleen, pancreas, etc. 

Gastric ulcers are situated, in the vast majority of cases, on the 
posterior wall — i.e., on the lowest part of the stomach when the 
posture is erect. According to the statistics of Brinton and Roki- 
tansky four-fifths of all cases are situated on the posterior wall, the 
lesser curvature, and the pylorus, so that the vast surface of the an- 
terior wall, the great curvature, the fundus, and the cardiac orifice 
are comparatively rarely seats of the disease. The comparative ex- 
emption of the anterior wall is most fortunate, in that there is here 
no viscus to which the stomach can be tied or glued in case of per- 
foration. The adhesions which do occur between the stomach and 
the abdominal wall are few and fragile, and are easily broken down. 
Ulcers, disclosed on autopsies, are found, of course, in every stage of 
ulceration or cicatrization. In fact, scars the results of ulcer are 
found in about half of all cases of gastric ulcer. The base of the 



374 ULCER. 

ulcer is usually covered with a gray slough. It may, however, be 
perfectly clean, as if dissected out. Sometimes the ulcerative process 
continues in the body of the viscus to which the stomach has become 
attached, and excavations, abscess formations, are thus found in the 
liver, spleen, pancreas, etc. More frequently fistulous communica- 
tions with the colon, duodenum, or small intestine result. Adventi- 
tious sacs may be formed, subphrenic abscess, or perforations may 
occur externally or by burrowing sinuses at some distance from the 
seat of the disease. 

Deformity of the stomach may result also from the process of 
cicatrization. The situation at the pylorus is thus peculiarly unfor- 
tunate, in that a cicatrix may contract the pylorus, to lead to more 
or less complete occlusion and gastrectasia, to simulate at times the 
condition produced by carcinoma. Hour-glass contractions about the 
centre of the stomach from girdled ulcers are curiosities occasionally 
encountered. The liability of haemorrhage is another accident which 
gives gravity to this disease. The ulcer may open vessels of some 
size, most frequently the splenic artery, or blood may ooze in quan- 
tity from distended or varicose veins in the vicinity of or about the 
edges of the ulcer. 

Etiology. — Ulcer of the stomach is a disease of adolescence rather 
than maturity and age. It is almost unknown before the age of ten. 
Among the cases collected by Brinton, but 0.08 per cent occurred 
under the age of ten. The disease begins to show itself about the 
period of puberty, and is encountered with especial frequency be- 
tween the ages of fifteen and thirty. Sex has an important influence. 
According to all statisticians the disease is more frequent in the 
female sex; 2:1, 3:1 are the proportions usually observed. Ulcer 
of the stomach is noticed especially in connection with chlorosis, with 
ansemia, menstrual disturbance, hysterical states. In one-fifth of 
the cases the condition is found in connection with tuberculosis of the 
lungs; in two-thirds of the cases* according to Steiner, with diseases 
of the heart and vessels, endocarditis, endarteritis. Ulcer of the 
stomach, in consequence of thrombotic occlusion with destroyed 
blood corpuscles, is also found to occur as the result of burns of the 
skin, though not so frequently as ulcer of the duodenum. 

The true cause of the condition is still obscure. It is generally 
attributed to the erosive action of the gastric juice, which does not 
attack the stomach wall in health, because the acid juice is neutral- 
ized by the alkaline blood. An interruption in the circulation 
which diminishes or withholds the blood supply permits the erosion. 
Cases have been observed in which embolus or thrombus, in con- 
nection with heart disease, atheroma, lues, has been observed, but 
in the majority of cases the cause eludes detection. 



ULCER. 375 

The revelations of the stomach tube have made it plain that in 
the majority of cases of ulcer the gastric juice is excessively acid. 
This hyperacidity is one of the points of differentiation between this 
disease and cancer. The ulcer has been attributed to the erosive 
power of this excessive acidity. It is difficult to understand why the 
ulcer should assume its particular shape under such action. Yet the 
situation of the ulcer at the surface of longest and closest contact 
with the stomach wall points to a development under destructive 
action. Panum found that he could produce hemorrhagic erosion 
and ulcers of the stomach in animals by the injection into the arte- 
ries of insoluble particles. Ebstein and Schiff remarked that inju- 
ries of the nervous system, brain, and cord were attended with the 
same lesions. These accidents are due here, as in the case of burns, 
to thrombotic occlusions by dead blood corpuscles. Klebs calls in a 
spastic contraction of the arteries to account for certain cases, and 
Boettcher invokes the action of unknown micro-organisms. Vir- 
chow assumes that ulcer of the stomach may result from numerous 
causes. One may be, however, loath to accept such a view. The 
picture is so typical, the character of the ulcer so uniform, as to stamp 
the affection as an individual disease produced by a definite cause. 

Symptoms. — Ulcer of the stomach is sometimes latent. Ulcers 
have been found upon autopsy without sign of existence in life. 
More frequently an ulcer has turned up to satisfactorily account for 
a long-continued and obstinate dyspepsia or gastric catarrh. As a 
rule the disease is announced with a distinct train of symptoms. 
Pain is almost universally present. It varies in character, is some- 
times sharp, lancinating, sometimes dull, gnawing. A more charac- 
teristic feature is its more exact circumscription. The pain is located 
about the ensiform cartilage, at the umbilicus, in the back, at the 
middle of the dorsal vertebrae, or at the angle of the scapula. 
Wherever felt, it is more or less, localized in this region in an in- 
dividual case. Pressure upon the stomach rather intensifies than 
relieves pain. On the other hand, the pain is usually modified or 
abolished by change of posture. Individuals who feel pain only 
in lying upon the back or upon the left side, and who may be re- 
lieved by lying upon the face or the right side, are probably subjects 
of gastric ulcer. The situation of the ulcer may not be defined by 
the interval bet veen the ingestion of food and the perception of pain. 
The pain does stand in relation to the taking of food — no food, no 
pain It sometimes occurs quickly, sometimes after the lapse of 
time. In a case recorded by Busch pain occurred in twelve minutes 
after the taking of food ; the ulcer was found in the duodenum ; 
while in the case of Pinel the pain was felt immediately, and the ulcer 
was found at the pylorus. 



376 ULCER. 

Vomiting is the next most frequent sign. It is present in three- 
fourths of the cases, and when absent is thought to be due to the loca- 
tion of the ulcer in exceptional places, as at the fundus, anterior wall, 
etc. Vomiting, which discharges the contents of the stomach, relieves 
the pain. It stands more directly in relation to the character of the 
food. Irritant foods inevitably produce pain and vomiting. The 
presence of both pain and vomiting does not distinguish gastric ulcer 
from gastric catarrh; but the vomited matter in gastric ulcer some- 
times contains a distinctive feature in blood. Hcematemesis is a 
valuable sign. It distinguishes itself in gastric ulcer, as a rule, by the 
4 quantity of the blood which is ejected. The physician is shown a 
basin or a bowl or a vessel filled with blood, and the patient is found 
exsanguine. Individuals have died of concealed haemorrhage in 
cases which have thereby assumed juridical importance. The sto- 
mach has been found full of blood and the intestinal canal distended 
through its entire length. In many cases the blood is not vomited, 
but is discharged by the bowels. Haemorrhage ivould be discovered 
more frequently if the stools were more closely inspected. Black, 
tarry matter is found in the discharges in these cases. In the expe- 
rience of the author a mass of inspissated blood had to be removed at 
one time from the rectum with instruments several days after a 
haematemesis. Haemorrhage is the most obtrusive sign of gastric 
ulcer. Unfortunately for the diagnostician, it is not present in even 
the majority of cases. It occurs in not quite one-half of the cases, 
and may be recognized when it occurs, in the absence of apparent 
blood, by faintness, nausea, vertigo, collapse, sometimes convulsions. 
Haemorrhage is peculiarly liable to recur with the detachment of a 
clot which blocks the vessel. 

Along with ulcer of the stomach is associated always that train 
of symptoms known under the term dyspepsia. There is anorexia, 
distaste for food, eructation of gas and fluids, heartburn, depression 
of spirits, and, in chronic or protracted cases, impairment of nutrition. 
On the other hand, many cases show a bien-etre. The author had 
under observation the case of a man whose weight varied little from 
two hundred and fifty pounds. In this case signs of ulcer showed 
themselves with every dissipation. The signs included haemorrhage, 
which at last proved fatal. Constipation is marked, as a rule, and 
is frequently obstinate. 

The excess of hydrochloric acid in the gastric juice consumes the 
chlorides, so that the urine is distinguished by absence of chlorides 
and increase of alkalinity. The test made by a solution of silver ni- 
trate is very easy and very valuable. 

The duration of the disease is indefinite. Brinton recorded a case 
which lasted thirty-five years. The usual history is one of recovery- 



CANCER. 37? 

with cicatrization, reopening of the cicatrix after some insult to the 
stomach, and a repetition of the symptoms. It is, however, true that 
the majority of cases recover permanently after a single attack. The 
prognosis, on account of the possibility of perforation, is always 
grave. 

The diagnosis rests upon the age, sex, history of previous attack, 
dyspepsia, pain, vomiting, haematemesis. The diagnosis is often very 
easy, especially in the presence of copious haemorrhage. The only 
disease which simulates ulcer in this regard is cirrhosis of the liver, 
in which haemorrhage is frequently profuse and not infrequently 
fatal. Cirrhosis hepatis is rare. It is a disease of the male sex in 
the vast majority of cases. It results from alcohol and is associated 
with other signs, dropsy, enlarged veins, marasmus, etc. The dif- 
ferentiation of diseases of the stomach from each other is discussed 
later. It is in this connection that the diagnosis is difficult, some- 
times actually impossible. 

Treatment. — The best food is milk when it can be borne, later 
beef or beef -pancreas emulsion. Starchy food, must be avoided, as, 
while meat is well digested, starch is not attacked. Haematemesis 
is an absolute contra-indication of all food by the mouth. Support 
for a few days may be had by the rectum (see Food). In the pre- 
sence of copious haemorrhage an ice bag is put at the epigastrium. 
Ergotin may be injected subcutaneously or sclerotinic acid in sy- 
ringeful doses. Pain may be controlled by bismuth gr. x.-xx. every 
two hours, or nitrate of silver gr. -j— J, or chloroform gtt. v. in a 
tablespoonfnl of water, or cherry -laurel water 3 i., or morphia gr. -J- J. 
Constipation is best relieved by Carlsbad salts, a teaspoonful in a 
glass of hot water before breakfast, or more safely in recent cases by 
enemata. Perforation calls for laparotomy, already successfully per- 
formed by Parsons. The most essential factors in treatment are 
rest, abstinence from food, and time. As Jurgensen says, for ulcer 
of the stomach " hunger is the best cook and cure." 

CANCER. 

Carcinoma (HapKivo^, cancer, crab). — An epithelial overgrowth, 
probably caused by protozoa, in the region chiefly of the pylorus, 
which orifice becomes blocked ; characterized by pain, dyspepsia, 
diminution of secretion of hydrochloric acid and pepsin, vomiting of 
food, mucus, disorganized blood (coffee grounds), tumor, with pro- 
gressive emaciation, and death by inanition. 

History. — Up to the time of Morgagni (1760) cancer was called 
scirrhus {(juipo^ induration), and only that form of it which broke 
the surface to cause or show ulceration was known as cancer. 
The term scirrhus had reference only to hardness of structure. The 



378 CANCER. 

fact that cancer shows itself in various forms in the body is an 
acquisition of later date. Laennec (1812) first set apart the brain-like, 
encephaloid form. Otto (1816) recognized a peculiar gelatiniform 
degeneration that takes place in other forms, which he distinguished 
a,s colloid cancer. Rheinhardt (1851) discovered the form commonly 
known in other places as epithelioma. The absence of free hydro- 
chloric acid in cancer was first utilized in diagnosis by R. v. d. Velden 
(1871), though the fact was really first observed by Golding Bird (1842). 

Pathology and Etiology. — Up to this time it was believed that 
cancer might develop in any kind of tissue, but Thiersch (1861) and 
Waldeyer (1867) demonstrated that cancer is an epithelial growth, 
and that the varieties in density are largely due to the amount of 
connective tissue which constitutes the stroma of the growth. No- 
thing more definite is known of the nature of cancer of the stomach 
than of cancer elsewhere. The tendency at the present time is to 
regard cancer as an epithelial cell containing corpuscular elements, 
which are parasites (protozoa) or degenerated protoplasm or gran- 
ules. These corpuscular elements transmit or disseminate the dis- 
ease. They take root and grow in the new soil, extending like a 
living thing by continuity and contiguity of structure. 

It is universally recognized that the stomach is one of the most, 
if not the most frequent seat of primary cancer. The uterus is the 
only organ in the body which may dispute the field with the sto- 
mach. Tanchou found the uterus affected more frequently than the 
stomach by about seven per cent. Virchow gives the preference to 
the stomach. Welch, who makes his computation from 31,482 cases, 
puts the percentage for the stomach at 21.4, for the uterus 29.5 — that 
is, rather more than one-fifth of all primary cancers affect the sto- 
mach, somewhat less than one-third the uterus. Cancer of the sto- 
mach is, therefore, a frequent disease, though it is by no means as 
frequent as ulcer. Statistics with regard to the frequency with 
which cancer is found on autopsy vary from one-half to three and 
one-half per cent. It is claimed that one one-hundredths of deaths 
from twenty years up are caused by cancer. Sex shows no differ- 
ence. The predominance of males in hospital practice is due to 
the fact that males predominate at hospitals. Age has a most 
important influence. Steiner and Neureutter failed to discover a 
single case in two thousand autopsies of children. What cases 
have been reported under the age of twenty must be regarded with 
suspicion until the nature of the affection has been verified by the 
microscope. Some of these cases were undoubtedly sarcomata. Can- 
cer occurs with increasing frequency in advancing age. According 
to the statistics of Brinton three-fourths of patients are between 
forty and seventy, two -sevenths between fifty and sixty. The re- 



CANCER. 379 

duction in frequency after sixty is apparent and not real, and is due 
to the fact that few survive this age. In these statements the fact 
must not be ignored that cancer has been not infrequently found 
between the ages of twenty and thirty. 

It has been claimed that cancer of the stomach is less frequent in 
tropical countries. From lack of definite data these statements must 
be accepted with caution. Welch declares that, from his analysis of 
7,518 deaths among negroes, he finds the proportion one-third less 
than among whites. The role of heredity, formerly considered so 
important, has been reduced to insignificance in our day. Cancer is 
found in the ancestry of but fourteen per cent of cases — an infre- 
quency which makes a coincidence rather than a cause. 

When cancer affects the stomach it is situated, as a rule, at the 
pylorus. Of the three hundred and sixty cases of Brinton, the py- 
lorus was the seat of the disease in sixty, the cardiac orifice in but 
ten per cent. Eisenhart reports eighty-one cases, forty-four at the 
pylorus. Exceptional cases are found in other parts of the stomach. 
Cancer is seated at the orifices of the stomach in seventy-five per 
cent of cases — a contrast with ulcer, which is located at the orifices in 
but sixteen per cent of cases. Usually the disease is located as a 
mass or tumor which can for the most part be felt at the pylorus, 
whence it may extend to involve other parts of the stomach. In 
exceptional cases the cancer may diffuse itself more or less exten- 
sively over the anterior wall. It is in the vast majority of cases 
primary in the stomach. Where the disease has existed for any 
length of time it develops secondary deposits, first in frequency in 
the liver, which is found affected in one-fourth of all the cases; 
next in the peritoneum, then in the lungs, retroperitoneal glands, 
intestines, ovaries, etc. 

The most important questions in etiology revolve about the con- 
nection between cancer and catarrh. It is certainly true that in 
most cases cancer is associated with gastric catarrh, that the symp- 
toms of gastric catarrh belong to the symptomatology of cancer. It 
is, however, also true that in the majority of cases a diagnosis of 
cancer may be established at the start — that is. with the occurrence 
of dyspepsia. It is always impossible to know just when a cancer 
commences. The point of the utmost practical importance is the 
establishment of the exact relationship between cancer and catarrh. 
Cancer develops occasionally, but only exceptionally, in the borders 
of an ulcer, probably, however, only as a mere coincidence. 

May cancer of the stomach be prevented by arrest of gastric ca- 
tarrh ? It is impossible as yet to determine this question. Cancer is 
probably sui generis. Certain it is that cancer occurs among indi- 
viduals, seemingly in perfect health, who have subjected the stomach 



380 CANCER. 

to no abuse either with food or drink, while individuals who abuse 
the stomach in every way may remain exempt. Wo circumstance in 
the way of social standing, avocation, mental distress, or other sur- 
rounding seems to show any genetic relationship to the disease. 
When it is stated by the authorities that individuals who show 
cancer have had a predisposition to the disease, it may be seen to 
what extremity the pathologist is reduced in etiology. 

Symptoms. — Cancer of the stomach is often latent, and masses 
as big as the fist have been disclosed upon the post-mortem table 
whose existence was unsuspected in life. Siewecke collected one 
hundred and twelve cases without typical signs. It need scarcely 
be stated that these masses were situated away from the orifices of 
the stomach. Cancer shows signs early, as a rule, because it affects 
these orifices. As a rule the disease shows itself with a train of dis- 
tinct symptoms. Pain is present in nearly all cases. It is usually 
a dull, dragging sensation with epigastric distress. It may be felt 
most intensely in the back, about the vertebrae or the scapula, or 
lower down in front at the umbilicus, or at the pubes in cases of dis^ 
located pylorus. The pain of cancer is usually due to indigestion, 
and not infrequently to gaseous distention. It does not stand in such 
intimate relation to the taking of food as in gastric ulcer. It may 
occur only as a vague distress as the stomach becomes more and 
more full toward evening, and show itself in intensity throughout 
the night. Proof of this lies in the fact that it nearly always dis- 
appears when the stomach is emptied, naturally or artificially. The 
pain is usually prevented and a night's sleep secured by washing out 
the stomach in the evening. It may, however, be due to direct pres- 
sure of the carcinomatous mass upon nerve fibres, or exposure of 
these fibres in ulcerative processes, as in the case of gastric ulcer. 
Pain may be entirely absent throughout the whole history of the 
disease; in fact, in eight per cent of all the cases. It happens occa- 
sionally, but very exceptionally, that a case presents all the other 
symptoms of cancer, including the tumor, but shows no pain. The 
aged especially feel no pain. Along with the pain -are usually asso- 
ciated other symptoms of indigestion. 

Cancer shows dyspepsia early, as a rule. It literally ruins the 
appetite from the start. Cancer poisons the blood and brings about 
early degradation of the mind and body. Feltz found the urine of 
cancerous patients more toxic than that of healthy patients. Klem- 
perer observed that the injection of blood serum of cancerous patients 
into a dog brought about a quicker decomposition of the albumen, 
and Gros saw a foudroyant septicaemia supervene after the breaking 
down (softening) of a cancerous gland. Vomiting soon sets in, 
especially if the disease be situated at the pylorus. It may be due to. 



CANCER. 381 

mechanical obstruction, which leads to gastr ectasia and accumula- 
tion of food, mucus, detritus, until its final ejection en masse in 
large quantity. The discharge by vomiting of immense quanti- 
ties, basinfuls, of fluid once a day or once in two or three days, 
should excite the suspicion of dilatation of the stomach, the most 
frequent cause of which is cancer. This dilatation is discovered, 
also, often by percussion, which reveals dulness over an increased 
area; not infrequently by palpation, which, when practised with 
alternate hands, may give rise to a sense of succussion, a peculiar 
fluctuation caused by the presence of fluid and gas — what the 
Germans call a Schivappen-gefiihl. Vomiting may occur early, 










^/^"^'X^pf^ 



. _..v. . 



- ^£J& -V^ m 









lH$0P StfiipP 






Fig. 182.— Microscopic appearance of section of scirrhus carcinoma (Councilman). 

though the deposit of cancer be small. It may irritate the pylorus 
and lead to spastic contraction. Carcinoma at the cardiac orifice 
leads to vomiting early by irritative process, or, when pronounced, 
to regurgitation before the fluid has entered the stomach. Vomiting 
may be entirely absent in cases where the cancer is seated elsewhere 
than at the orifices — according to Lebert, in one-fifth; to Brinton, in 
one-eighth; to Ewald, in but one-twelfth of all the cases. 

Vomited matter, aside from its quantity, may reveal the nature 
of the disease by its character. Thus Rosenbach was able to diag- 
nosticate cases from fragments withdrawn by the stomach tube. 
The vomited matter at times contains blood. Hsemorrhage from 
the stomach is not so frequent or so copious in cancer as in ulcer. 
The blood is, as a rule, poured out into the stomach more slowly in 



382 CANCER. 

cancer. Acted upon by the gastric juice, it is disintegrated to show 
itself as coffee-ground matter. Vomiting of coffee ground matter 
is regarded as valuable evidence of cancer. Haemorrhage is copious 
in but twelve per cent of cases. In these cases, however, it may so 
closely simulate ulcer as to necessitate appeal to other signs in 
diagnosis. 

Blood may be recognized visibly, or by the microscope, or by 
Teichmann's chemical test. The following is Teichmann's test as 
given by Vierordt : Some of the coffee-ground material is filtered; a 
little of this matter is evaporated in a watch glass. Scrape off some 
of the dried material, mix it with a trace of finely pulverized salt, 
place the dried mixture upon an object glass, cover it with a glass 




Fig. 18'i— Hsemin crystals obtained by Teichm arm's test, enlarged 300 times 



cover, and allow one or two drops of glacial acetic acid to flow under 
it; then the acetic acid is again evaporated very slowly, and, after it 
is thoroughly dry, one or two drops of distilled water are allowed 
to flow under to dissolve any crystals of salt that may be present. 
Under the microscope there can be seen crystals of haemin (hydro- 
chlorate of haematin) in coffee-brown or reddish-brown crystals in 
rhombic plates, which must be considerably magnified, as the crys- 
tals are very small. 

The following method (an adaptation to the vomit of Heller's test 
for blood-coloring material in the urine, which see) leads to a result 
more quickly : Place some of the filtered stomach fluid in a reagent 
glass with a like quantity of normal urine, make it strongly alkaline 



CANCER. 383 

with liquor potassse, and heat it. The urine phosphates are precipi- 
tated and carry with them the coloring material of the blood, to show, 
when blood is present, a cloudy, flocculent, reddish-brown deposit. 

The most reliable evidence of cancer is furnished by the detection 
of a tumor. Tumor, at least localized induration, occurs in all cases, 
but may not assume sufficient magnitude to be detected in every 
case. In fact, taking the history of cases from beginning to end, 
the tumor is actually found in but eighty per cent of cases. In one- 
fifth of the cases of gastric cancer the diagnosis must be made with- 
out tumor. When present it is found in the majority of cases at the 
pylorus, the situation of which, however, is by no means always the 
same. The pylorus is very apt to be dislocated by the weight or 
growth of a cancer. Brinton calls attention to the transverse line 
midway between the ensiform cartilage and the umbilicus. The 
tumor is found in the majority of cases above this line in males, 
below it in females. It is at times recognized below the umbilicus, 
and very exceptionally, as stated, as low as the pubes. It is impor- 
tant not to mistake the lobe of the liver, the head of the pancreas, a 
rigid rectus, a distended colon, or other mass for a carcinoma. These 
things may be excluded only by careful examination. It is of su- 
preme value to be able to feel the tumor when present. The patient 
must often be put in various positions, on the right or left side, in the 
knee-elbow posture. The pylorus has a way of hiding itself behind 
the ribs, behind the liver, whence it may be dislodged at times by dis- 
tention of the stomach. Wagner has suggested and used the method 
of inflation by means of a seidlitz powder. The bicarbonate of soda, 
twenty or thirty grains, is dissolved in one glass of water, ten or fif- 
teen grains of tartaric acid in another glass, and the glasses are taken 
separately. Or, better, the powders are swallowed dry with sufficient 
water to dissolve them, whereupon the stomach becomes distended, to 
show at times peristaltic movements, through an attenuated or ema- 
ciated abdomen, or to dislodge the mass at the pylorus that may be 
felt. Runeberg accomplishes the same object by distending the 
stomach with air by means of a common air balloon or through the 
stomach tube. Affections of the colon may be differentiated by dis- 
tention of the intestine with water or gas. 

Up to the last decade it was maintained that the tumor formed 
the most valuable evidence of cancer. It is, however, by no means 
pathognomonic. In the first place, the tumor may not concern the 
stomach ; in the second place, a tumor of the stomach may be be- 
nign. The discovery by Van der Yelden, 1871, of the absence of 
free hydrochloric acid in cases of gastric cancer was hailed with 
acclamation. The discovery was made with the claim that the acid 
is absent in cancer, present in ulcer and catarrh. The claim has 



384 CANCER. 

since met with modification. It is known that exceptional cases of 
carcinoma show free hydrochloric acid, and that free hydrochloric 
acid may be absent also in cases of catarrh, or more especially de- 
generations other than cancer. Nevertheless it is true that the acid 
is absent as a rule in cancer, but is present as a rule in ulcer in 
excess, in catarrh in reduced amount, so that at the present time it 
may be declared that the persistent absence of free hydrochloric acid 
speaks strongly for carcinoma. Riegel considers the sign more valu- 
able than the tumor. Probably few clinicians will coincide with 
him to this extent. The tests for free hydrochloric acid have been de- 
scribed in connection with catarrh of the stomach. There may or 
may not be much loss of nutrition. As a rule the strength fails 
with the loss of flesh, and the progressive emaciation and prostra- 
tion are to be attributed partly to anorexia, mainly to dyspepsia in 
its true sense, somewhat also to infection of the blood. Exceptional 
cases preserve weight up to the last days of the disease. As a rule 
the degradation is marked by cachexia. With the progressive loss 
of weight there is corresponding depression of spirits. The expres- 
sion becomes listless, melancholic. The face assumes a greenish- 
yellow tinge, the tongue is coated. There is oedema of the ankles 
and progressive marasmus. 

The diagnosis, which is studied more closely later, rests upon the 
age, absence of hydrochloric acid on account of disease of the 
mucous membrane, pain, vomiting, especially of large quantities, 
or of coffee-ground matter, tumor, progressive course, etc. The 
presence of sixty per cent hgemoglobin excludes cancer (Haberlin), 
and thus distinguishes cancer from pernicious anemia, which shows 
absence of HC1, but increase of hemoglobin (Mouisset). But the 
same blood changes found in cancer are sometimes seen in ulcer 
(Osterspey). 

It is impossible to fix the duration of cancer, because the date of 
origin may not be established. An average case lasts from six to 
fifteen months. The general duration ranges from one to three 
years. Cancer may become quiescent. The patient often succumbs 
to metastatic deposits, especially in the liver. Sudden coma may 
supervene, as in diabetes, from diminished alkalescence of the blood 
and development of oxybutyric acid, or from absorption of toxic pro- 
ducts (gases, etc.) in the stomach. The prognosis is fatal. 

The treatment is wholly symptomatic. The daily or nightly use 
of the stomach tube gives the most relief. An early diagnosis — i.e., 
before implication of the liver or metastatic deposits — justifies the use 
of the knife, which is, of course, a confession of despair. Condu- 
rango prolongs life. Opium secures euthanasia. Hope lies in eti- 
ology and prophylaxis. 



GASTRECTASIA. 385 

GASTRECTASIA. 

Gastrectasia (yaarrjp, stomach, exraaii, dilatation). — Dilatation 
of the stomach results most frequently from occlusion of the pylorus, 
and occlusion of the pylorus is caused, in the majority of cases, by 
cancer. The block is mechanical, but before the mass accumulates 
to such extent as to completely occlude the pyloric orifice it is shut 
off by spastic contraction of its muscle under irritation of the altered 
contents of the stomach as well as of the growth itself. It is, how- 
ever, a serious and not uncommon mistake to assume that every case 
of dilatation depends upon cancer. Certain cases are caused by the 
constriction of cicatrices from ulcers. The pylorus is a favorite site 
of ulcer, and the coalescence of two or more ulcers may make some- 
thing of a girdle, the cicatrization of which may close the gate. So 
the pylorus may be blocked by outside cause, as by an impacted gall 
stone, tumor, aneurism, abscess, as of the vertebrae, etc. 

Independently of any occlusion of the pylorus, dilatation of the 
stomach may be due to intrinsic cause, more especially to paresis of 
the stomach wall, the result most frequently of a chronic gastric 
catarrh. Affection of a mucous membrane for any length of time 
involves, in the course of time, the submucous muscular coat. It 
loses tone, it fails to empty the stomach, and, even when hypertro- 
phied as the first result of an occlusion of the pylorus, it must sub- 
sequently become weakened, degenerated, overcome. Fatty degene- 
ration, extensive atheroma, more especially amyloid degeneration, 
lead also to dilatation. In undergoing dilatation the stomach in- 
creases in all its diameters. The fundus fills the left hypochondrium, 
the great curvature extends to and below the umbilicus, the pylo- 
rus reaches over into the right hypochondrium. There is frequently 
direct interference with the action of the diaphragm and the heart. 
The increase in size of the stomach is recognized in emaciated sub- 
jects by inspection. It may be brought out more distinctly by in- 
flation of the stomach with air, or with carbonic acid gas in the 
manner already described. So, too, the body of the stomach and its 
outlines become evident to percussion. There is increased dulness, 
increased tympanites, as the stomach is more or less full of fluid or 
gas in every direction. It seems often as if the stomach fills the 
upper half of the abdominal cavity, or comes to lie diagonally across 
it in cases of downward dislocation of the pylorus. Palpation dis- 
tinguishes often a kind of fluctuation, due to the presence of water 
and gas, and a sort of succussion — Klatschgerdusch — a very valuable 
sign. On introducing the stomach tube it seems impossible to find 
bottom, it extends so much further than in a healthy stomach. 

Suspicion is frequently excited as to the existence of this condi- 
25 






386 GASTRECTASIA. 



tion by the character of the vomit. Large quantities, more than a 
normal stomach could hold, may be ejected at once, often with much 
subsequent relief, and this accumulation to distention and ejection 
repeats itself in the course of every few days. The Duke de 
Chausnes, a famous gourmand of Paris, was in the habit of vomit- 
ing a gallon at a time, and common washbowls are often filled with 
the rancid discharges of gastric catarrh and cancer. The vomited 
matter shows signs of decomposition. The antiseptic action of the 
gastric juice is overcome by the acetic and butyric fermentations. 
The matter contains also sarcinse with various micro-organisms 
which are destroyed in the healthy stomach after the hydrochloric 
acid becomes free. 

The absorption of gases from the stomach leads to various nervous 
symptoms. In most cases there is depression of spirits. The condi- 
tion is commonly encountered in the case of hypochondriacs. Occa- 
sionally symptoms of greater gravity show themselves. These are 
the patients who sometimes fall into states of coma to be mistaken 
at times for apoplexies. Coma belongs to gastrectasia as well as to< 
diabetes, and results, as in diabetes, from a peculiar acid intoxication 
of the nervous system through the blood. There is in these cases 
the same peculiar alteration of respiration, the same deep, forcible 
breathing, and the same fatality seen in diabetic coma. 

In diagnosis the condition must be distinguished from distention 
of the colon. Doubt may be cleared up by filling the colon with 
water or air. Dropsy, as from cirrhosis or other ascites, cystic tu- 
mors of the pancreas, ovary, etc., may be, as a rule, readily ex-- 
eluded. 

The pi^ognosis takes color from the cause. Gastrectasia due to 
cancer has a fatal prognosis; due to stricture, has a prognosis favor- 
able or fatal, as the stricture may be accessible to the sound or the 
knife after laparotomy. Gastrectasia due to catarrh or paretic con- 
ditions of the muscular tissue -may be entirely relieved. 

In treatment main reliance is placed upon the use of the stomach 
tube, whereby the stomach is thoroughly emptied, its irritating con- 
tents removed, and the patient properly fed with appropriate food. 
Even the irremediable cases secure great relief of suffering in this 
way. Pain, eructations, heartburns, vomiting, insomnia, depres- 
sion of spirits, all disappear often after the first use of the stomach 
tube. Under the continued use of it once or twice a day, as may be 
necessary, the underlying condition is addressed, if it may be reached 
at all, with appropriate remedies. Digestion may be stimulated by 
hydrochloric acid gtt. x.-xv. in a wineglass of water before meals ; 
by bitter tonics, gentian, cinchona, condurango, more especially by 
the tincture of nux vomica gtt. x.-xx. in a wineglass of water before 



GASTRALGIA. 387 

meals • strychnia itself ; faradization. The stomach may be flushed 
and the associate constipation overcome by the use of Carlsbad salts 
(artificial), a teaspoonful in a glass of hot water before breakfast ; or 
tone may be imparted to a weak- walled stomach by rhubarb in the 
form of the compound pill, cascara sagrada in tablet or cordial. It 
goes without saying that in these patients the habits of life must be 
regulated as regards exercise, food, surroundings. 

Operative procedure in mechanical occlusion from cancer is re- 
duced in our day to a resection and gastroenterostomy. 

GASTRALGIA. 

Gastralgia {yaffrrjp, stomach, aXyol, pain) — neuralgia of the 
stomach — belongs among the neuroses of the stomach. Of these 
neuroses it is about the only one whose nature we know. The tro- 
phic neuroses, the secretory neuroses, which produce alterations in 
the structure and function of the cells, and which preside over the 
formation and flow of the gastric juice, are mostly beyond our ken. 
Attempt has been made to estimate the mechanical movements of 
the stomach — that is, to know something of the motor neuroses — by 
observing the length of stay of food in the stomach. A healthy 
stomach should empty itself completely in seven hours after the in- 
gestion of a certain meal. Food found in the stomach at or after 
this time indicates lack of tone in the muscular coat. Ewald endeav- 
ored to discover the rapidity with which a substance was moved out 
of the stomach into the intestine by the use of agents which, insolu- 
ble in the stomach, were dissolved in the intestine to be absorbed by 
the blood and show themselves in secretions. Thus salol is insoluble 
in the stomach, but soluble in the intestinal juice, where it is resolved 
into carbolic and salicylic acids. Salicylic acid is quickly eliminated 
from the kidneys, and recognized in the urine by the addition of a 
few drops of the tincture of the chloride of iron, which imparts to the 
fluid a deep-brown color. Salol may be recognized in the urine in 
half an hour to one hour after its ingestion into the healthy stomach. 
A failure to recognize it for two to three hours indicates disease. 
The objections to estimates made by this method are that, first, there 
is sometimes delay in physiological states; second, the method re- 
quires examination of urine and such an amount of time as to make 
it impracticable. Penzoldt next administered pills of the iodide of 
potassium, coated with keratin, which met both these objections, in 
that the iodine is recognized in the saliva in from six to twelve min- 
utes after its ingestion into a healthy stomach. It is only necessary 
in these cases that the patient should expectorate upon a piece of 
filtering paper saturated in a solution of starch. The iodine in the 
saliva strikes a blue color at once. In cancer at the pylorus, witlx 



388 GASTRALGIA. 

dilatation, absorption is delayed often one hour, at the fundus often 
twenty minutes. Unfortunately the keratin envelope is sometimes 
dissolved in the stomach to invalidate conclusions, so that up to the 
present time this testimony can be regarded only as corroborative, 
and the most practical deductions are drawn from the presence or 
character of the contents of the stomach as withdrawn by the sto- 
mach tube. 

Pathology and Symptomatology. — Gastralgia is an affection of 
the sensitive nerves. The condition manifests itself in pain, which 
is often excessively severe. Gastralgia is, as the name implies, a 
neuralgia of the stomach. Strictly speaking, the condition as a sepa- 
rate disease is a pure neurosis. There is often, however, very great 
difficulty in separating neuroses from organic affections. All the dis- 
eases of the stomach are marked by pain: gastric catarrh, gastric 
ulcer, gastric cancer are all associated with pain. Attacks of gas- 
tralgia occur in connection with all these diseases, but gastralgia is 
considered as a separate disease only when dissociated from organic 
affections. True gastralgia occurs as the result of abnormal ingesta — 
abnormal in themselves or abnormal to the individual on account of 
idiosyncrasy — or is the result of the altered condition of the stomach 
nerves, a kind of hypersesthesia. Finally it may be reflex. It is not 
exactly true that what is one man's meat is another man's poison, but 
it is true of some things in certain cases. Shell fish not infrequently 
excite attacks of gastralgia. There are individuals who may not 
partake of oysters, many more who may not eat clams, without suf- 
fering pain. Ice water produces attacks in certain individuals, straw- 
berries in others. There are not lacking individuals who suffer after 
taking milk. These abnormalities may develop when they may not 
have existed before, in or after attacks of illness of various kinds. 

In the majority of cases gastralgia is the result of an altered ner- 
vous system. A large number of cases occur in hysterical females, 
especially in connection with menstrual disturbances, or with indi- 
viduals who show other neuroses, asthma, migraine, or other neu- 
ralgias. Gastralgia is often an outward sign of an underlying con- 
dition, an unstable, mobile, excitable state of the nervous system. 
This condition is sometimes produced by excesses which lead to ex- 
haustion, by alcohol, tobacco, tea, and coffee, more especially by dis- 
eases which sap the nutrition or directly poison the nervous centres — 
anaemia, diabetes, Bright's disease, malaria, rheumatism, etc. 

Under the head of reflex causes are diseases of the genito-urinary 
system, various affections of the uterus and ovaries. Salpingitis and 
prostatitis have been found to produce exquisite gastralgias. In cases 
where relationship has been established cure of the cause cures the 
consequence. 



GASTRALGIA. 389 

Gastralgia shows itself in acute and subacute or chronic forms. 
In the acute attack the pain comes on suddenly, often without pre- 
monition, and distinguishes itself by its intensity. The pain is located 
at the pit of the stomach, or irradiates thence to the back or sides, 
and is frequently associated with a precordial pain and anxiety. Cer- 
tain cases of pseudo-angina are cases of gastralgia. The attack is 
often associated also with the various symptoms of dyspepsia, and is 
relieved at times by the discharge of large quantities of gas, at times 
again by a profuse sweat. In the more chronic cases the pain is less 
intense ; it is more continuous. There are intervals of comparative 
relief, with attacks at times excruciating in severity, especially as 
the result of any imprudence in diet or exposure to cold. 

Diagnosis. — Gastralgia must be separated from intercostal neu- 
ralgia, enteralgia, muscular rheumatism, gall-stone colic, and the 
dyspepsias of organic diseases. Location of the pain usually suffices 
to distinguish neuralgia of the stomach from that of the intestine. 
The discovery of painful points between the ribs, near the sternum, 
in the axillary line, and in the vicinity of the spinal column suffices 
to separate intercostal neuralgia. Muscular rheumatism, pleuro- 
dynia, is more especially aggravated by motion and is unattended 
with dyspeptic phenomena. Gall-stone colic affects more especially 
women past the middle period of life. The condition may be dis- 
tinguished by the existence or history of jaundice, by a distended gall 
bladder. Hepatalgia may be separated from gastralgia only by the 
fact that the pain is more strictly localized in the region of the liver. 
It is of much more importance to be able to recognize the cause of 
the dis.ease, whether due to food, bad habits, chlorosis, Bright's dis- 
ease, etc., as the future of the case depends entirely upon its cause. 
In locomotor ataxia the attacks occur as " crises/'' caused by scle- 
rosis of the vagus at its origin and in its course (Landouzi). The 
gastralgias of hysteria occur in connection with psychical disturb- 
ance and alternate with other neuralgias. Reflex gastralgias are 
most pronounced in pregnancy and the puerperium. 

Gastralgia is for the most part a curable- condition. It is often a 
relief to the practitioner to be able to discover a pure neurosis as dis- 
tinct from an organic disease. 

Treatment. — Sometimes the pain is relieved at once and the na- 
ture of the disease recognized by a single application of the galvanic 
current, anode between the shoulders, cathode at the pit of the 
stomach. Electricity seems to have more direct control over these 
than over any other forms of neuralgia. The daily application of a 
mild current for five minutes for several days suffices to cure simple 
cases. The diet and habits of life must be regulated. Chlorosis 
is treated with iron ; a tablespoonful of the simple carbonate with 



390 DIAGNOSIS, DIET, AND TREATMENT OF 

about half a tablespoonful of sugar of milk three or four times a day 
makes an eligible preparation. The compound mixture of iron, 
though an inelegant, is a very efficacious form. It may be substi- 
tuted later with a compound pill of iron. It may be deemed advis- 
able to give the iron in combination with hydrochloric acid, whereby 
it is preferable to administer the drugs separately. The value of 
arsenic has always been recognized ; three to five drops of Fowler's 
solution of arsenic in a tablespoonful of water after meals is almost 
routine practice. Bismuth, in doses of ten to twenty grains after 
meals, proves often of great value. The salicylates, salol, especiall}- 
of soda, gr.vij.-x. every two to three hours, act often like specifics. 
Tincture of nux vomica gtt. x.-xx. in a tablespoonful of water, or 
strychnia gr. T V- T V> are tonics to the nervous system. 

The immediate pain must be relieved by anodynes. Two to five 
grains of chloral in a dessertspoonful of peppermint water often give 
quick relief. A teaspoonf ul of bitter-almond water may suffice for a 
milder case. A severer case calls for opium, best in the form of mor- 
phia ; gr. T V-g— i in a teaspoonf ul of cherry-laurel water relieves 
most cases. In the presence of excruciating attacks resort must 
be had to morphia subcutaneously, best combined with atropia gr. 

JO 1 

12 9 !• 

DIAGNOSIS, DIET, AND TREATMENT OF THE VARIOUS DISEASES OF 

THE STOMACH. 

The separation of the different forms of disease of the stomach is 
often easy, but is sometimes very difficult. The differentiation of can- 
cer from chronic catarrh and of gastralgia from simple ulcer becomes 
at times a real problem in diagnosis. There is in no case any one 
single symptom which may determine the exact character of the dis- 
ease. Even the tumor which is supposed to be pathognomonic of 
cancer is often deceptive. The diagnosis is made by the considera- 
tion of all the facts as elicited under patient investigation. There is 
to be considered first, age. An affection of the stomach past the 
middle period of life is more probably cancer, or, if of long duration, a 
protracted catarrh. Affections of younger middle age are more likely 
to be gastralgia and ulcer. To these rules, however, there are many 
exceptions. Cancer is sometimes encountered between twenty and 
thirty. An ulcer may last over and prove recurrent at a later period 
in life, while gastralgia and catarrh may occur at any time. The 
sex of the patient speaks rather in favor of ulcer and neuralgia as 
against cancer and catarrh. A large contingent of cases of gastral- 
gia occur, as stated, in chlorotic and hysterical females. Ulcer of the 
stomach is seen also under like conditions. Catarrh occurs rather 
more frequently in the male sex, while cancer is no respecter of sex 



DISEASES OF THE STOMACH. 391 

at all. Something may be learned at times by the appearance of the 
individual. Neuralgias and ulcers do not, as a rule, disturb the gen- 
eral appearance; though frequently attended with loss of flesh, they 
are not inconsistent with an appearance of health. Chronic catarrh 
is commonly found in hypochondriacal patients. Cancer produces 
in the course of time that peculiar degradation which is called a ca- 
chexia. The cachexia is, however, not peculiar to cancer. It may 
occur in any long-standing, wasting disease— tuberculosis, Bright's 
disease, etc. — but shows itself, as a rule, rather earlier in cancer be- 
cause of the early attack upon nutrition. Exceptional cases of can- 
cer show, however, no cachexia and no marasmus until the very last 
days of the disease. 

The cause of the condition, in so far as it may be discovered, may 
be invoked in explanation. Gastric catarrh may be found associated 
with irregularities or imprudences in diet, or as an expression of 
tuberculosis or Bright's disease. Gastric ulcer may be found asso- 
ciated with heart affections or with hyperacidities of the gastric juice. 
Gastralgia occurs in connection with or alternative to migraine, 
asthma, though neuroses may be found to have been caused by 
abuses of alcohol, tea and coffee, tobacco, bodily excesses, etc. Cancer 
has no known cause. Of the symptoms proper, pain is predominant. 
It occurs in all the varieties of stomach disease, but shows points of 
distinction in different forms. The pain of catarrh is more diffuse, 
more or less constant, with exacerbations, dependent more particu- 
larly upon distention. It is relieved by eructations, more especially 
by emptying and irrigating the stomach. The pain of ulcer is more 
strictly circumscribed. It is certainly more dependent upon the tak- 
ing of food. As a rule, no food, no pain. It is brought out, intensi- 
fied, mitigated, or relieved by change of posture. The pain of cancer 
does not differ very much from that of chronic catarrh. It is apt to 
be associated with more tenderness to pressure in the right hypo- 
chondrium. It disappears, like that of catarrh, with the emptying of 
the stomach. Gastralgia is for the most part a paroxysmal pain. It 
is frequently relieved by pressure, more frequently by the ingestion 
of food. When not more or less continuous it is most assertive when 
the stomach is empty. It is often much more intense. It is more 
amenable to relief. It may disappear entirely under antiperiodics, 
antineuralgics, or under the constant current of electricity. 

The appetite is permanently ruined in cancer, may be good in 
the intervals of attacks in ulcer, and is mostly good in gastralgia. 
The tongue is coated in cancer, but clean, as a rule, in ulcer and 
gastralgia. 

Vomiting may occur in any form of stomach disease, but is less 
apt to show itself in gastralgia. The vomiting of catarrh and cancer 



392 DIAGNOSIS, DIET, AND TREATMENT OF 

is more prone to occur in states of dilatation, when the stomach dis- 
charges large quantities of decomposing and fermenting matter. 
Blood is vomited only in ulcer and cancer. There may be excep- 
tional cases of violent retching in which the vomited matter or the 
ropy mucus discharged in catarrh may be streaked with blood, but 
the presence of blood is an exception. Blood may be vomited pure 
in both ulcer and cancer. It is much more frequently pure in ulcer, 
where it is present also in greatest quantity. It shows more fre- 
quently the coffee-ground appearance in cancer, as disintegrated by 
the action of the gastric juice. Blood may, however, assume either 
character in exceptional cases of either disease. 

The penetration of the stomach tube to unwonted depths speaks 
for dilatation of the stomach which in younger individuals is found 
in connection with catarrh; in rarer cases as the result of a cicatrized 
ulcer at the pylorus; in older individuals with cancer. Tumor, when 
detected unmistakably, speaks for cancer. There is room here for 
error with reference to outside tumors, as of the liver, pancreas, 
retroperitoneal glands, or intrinsic tumor, benign tumor, hyperplastic 
tissue from catarrh, or about an ulcer, etc. The gastric juice shows, 
as a rule, a reduction of acidity in catarrh, absence altogether in can- 
cer, an increase in ulcer, an unaffected condition in gastralgia. In 
this way the diagnosis is reached as a rule. Ulcer is the condition 
most frequently overlooked and confounded with or considered as a 
simple gastric catarrh. Cancer remains often unrecognized until it 
displays itself as a palpable mass at the pylorus. But by the inter- 
rogation of a patient from these various standpoints, the diagnosis, 
as stated, is reached as a rule. 

Diet. — The dietary is a most important question in the manage- 
ment of stomach disease, and may be considered here in some detail 
and in connection with the general subject. In the treatment of 
diabetes, obesity, as well as in stomach disease itself, it assumes more 
importance than the materia medica. During the existence of fever 
the body wastes more rapidly, and this waste must be compensated 
by the administration of food. Food must be administered, there- 
fore, as much as may be handled and disposed of by the stomach. 
Any fault in this regard of quantity or quality does damage, in that, 
undigested, it decomposes and remains as foreign matter, to be dis- 
charged by the act of vomiting or to become decomposed and add 
noxious elements to the blood. The most important food in all cases 
is water. Sixty per cent of the body is water. Water is necessary 
for the fluidification of the food as well as for the circulation of the 
blood and other juices. All water contains salt, notably lime salts.. 
One-half of bone tissue is made up of the lime phosphate; the 
sodium and potassium phosphates make the blood alkaline, and 



DISEASES OF THE STOMACH. 393 

alkalinity of the blood is a very necessity of existence. Water con- 
tains also the sodium chloride which enters into the composition of 
all the tissues. Sodium chloride, however, exists in such an insuffi- 
cient quantity in water that it must be continually furnished by solid 
elements of the food and in the preparation of food. The sodium 
chloride holds the globulin in solution; it regulates also the diffusion 
of fluids through animal membranes in the process of osmosis. 
Necessary as water is in health, it is even more necessary in disease. 
Water is constantly being given off from the body, from the skin 
and the various secretions, but especially from the skin in fever to 
secure the reduction of temperature, and from the kidneys in the 
elimination of toxines. Water must be, therefore, administered 
freely to all fever patients. It should stand always in reach or be 
periodically administered. The water must be pure. Cases of gas- 
tric and intestinal catarrh often fail to yield to treatment because the 
diseased state is kept up by the administration of contaminated 
drinking water. In all cases of doubt the water must be filtered 
through asbestos or porcelain, or boiled. 

The stomach is spared much of its work by the administration of 
food in fluid form. The best food is milk. Milk is a complete food. 
It has the advantage, in the first place, of fluidity; it has the great 
disadvantage that it will not keep. Another disadvantage lies in the 
fact that, though administered in fluid form, it often becomes solid and 
is rejected as a coagulated mass. . To obviate this evil, milk is some- 
times substituted by buttermilk. Buttermilk is a good substitute 
in summer ; buttermilk is bad in winter. Artificial fermentations 
may substitute milk, as in the form of kumyss, the taste of which is 
objected to by many patients. To obviate the evil of coagulation it 
is only necessary to dilute milk. This dilution may be secured in 
cases of intestinal catarrh, or excessive sensitiveness of the stomach, 
with lime water J-f. Coagulation is sometimes prevented by the 
addition of a small quantity of bicarbonate of soda. The best solu- 
tion is secured with soda water, Apollinaris or Selters (imported) 
water, half and half. In this dilution the milk is never coagulated 
en masse, and is very rarely rejected by the most delicate stomach. 
In this exceptional case, or where it is deemed advisable to change 
the form of the milk, the curd may be separated and the milk given 
in the form of whey. A teaspoonful of lemon juice added to a pint 
of milk secures this separation, and the whey may be made richer if, 
during the process of straining, the curd be squeezed that only the 
casein be retained. This whey may be administered by itself or in 
combination with various other foods, with diluted eggs, with bread 
crumbs, with a dash of rum or brandy, or with wine. 

Egg is also a complete food, but too concentrated for a diseased 



394 . DIAGNOSIS, DIET, AND TREATMENT OF 

stomach or for the febrile condition. To be digested it must be 
diluted with hot water and administered thus pure or after strain- 
ing through a linen cloth. An egg in a glass of sherry is concen- 
trated nutrition. Diluted egg in wine whey in a cup of tea, with or 
without a teaspoonful of cognac, is strong food. Custards of milk 
and egg are delicate, palatable, and nutritious. 

Beef is best administered raw. Scraped raw beef, teaspoonful to 
a tablespoonful — that is, the extract of the protoplasm without the 
fibre — mixed with a little warm water, seasoned with pepper and 
salt, forms concentrated nutrition. The taste is repulsive to some 
patients. A piece of beefsteak may be then very lightly broiled, that 
the aroma of cooking may stimulate the flow of the digestive juices. 
According to the experiments of Fick the stomach digests raw three 
times as quickly as cooked meat. Beef tea, chicken soup, mutton 
broth, are valuable contributions to the dietary. The best beef tea is 
made by taking a pound of lean beef, cut in strips the size of the 
finger, and a pint of cold water, to which is added a teaspoonful of 
salt. It is to be allowed to simmer fifteen minutes, but not to boil. 
A stronger preparation, known as beef essence, is prepared by placing 
the strips of cut meat or chopped beef in a wide-mouthed bottle, 
which is inserted into a vessel of boiling water and allowed to remain 
for half an hour. Beef tea or bouillon may be used also as a basis, 
to which may be added crumbs of bread, or strained egg, or various 
vegetables, whose juice and flavor may be taken without the sub- 
stance. Carrots, turnips, parsnips, celery, are vegetables used in this 
way. The juice of the fresh oyster is a stimulating, nutritious food 
which the most delicate stomach will rarely reject. The soft part of 
the oyster itself, the body without the muscle, is, as a rule, easily di- 
gested. It must be taken fresh from the shell, with pepper and salt, 
lemon juice, and horseradish. The white meat of fish, if properly 
prepared — an art seldom understood in inland places ("forty reli- 
gions and but one sauce ") — is delicate food. Sweetbreads stewed in 
milk are very digestible. The white meat of broiled chicken, phea- 
sant, quail, short-fibred meat, is much more easily handled than 
that of geese, ducks, wild fowl, wild game. There is often crav- 
ing for farinaceous food. The simplest forms are the gruels : a 
glass of water with a piece of toast inserted into it, cornmeal gruel, 
oatmeal gruel, barley, rice. Milk may be thickened with flour, with 
arrowroot or tapioca as articles of light diet for fever or for gastric 
catarrh. Fine white bread of wheat is much more easily digested 
than that from any other grain. Starch may be tried first in the 
form of toast. The " zwieback " is a good beginning. Coffee and 
tea are often necessary stimulants and adjuvants. They ma}" be 
even fortified with rum or brandy, or the coffee may be made black, 



DISEASES OF THE STOMACH. 395 

as in cases of heart failure, opium poison, etc. As a rule these beve- 
rages are not contra-indicated in fevers. The value of them in these 
states depends more upon the stimulation of heat which is thus in- 
troduced into the stomach, and they are made more palatable by the 
flavor of tea and coffee. They may be advantageously substituted 
often by chocolate, which imparts more solid nutrition; or, in cases of 
intestinal catarrh, by cocoa, a light form of which is found in the so- 
called acorn cocoa. It may become a necessity at times in the treat- 
ment of disease of the stomach, especially in cases of ulcer or in the 
presence of haemorrhage, to abstain from food altogether and support 
the patient by nutrient enemata. Enemata are poor substitutes at 
best . Baumler has shown that only about one-fourth of the most nu- 
trient matter is absorbed from the rectum. The beef -pancreas emul- 
sion of Leube may be used in this way. Foods which have been 
partly predigested, as in the case of the peptonized preparations, may 
be tried by the rectum as well as by the stomach. 

In the treatment of chronic gastric catarrh Leube's series of four 
diet lists, graded from the lightest up, is as good as any: 1. Bouillon, 
Leube-Rosenthal meat solution (beef boiled twenty-four to thirty-six 
hours, with the addition of dilute hydrochloric acid), milk, raw egg, 
zwieback, crackers (without sugar), Apollinaris, Selters, Vichy water. 
2. Boiled calves' brains, thymus gland of calf (sweetbread), boiled 
chicken (young without skin), boiled calves' feet, milk gruels with 
tapioca, whipped egg. 3. Raw beef chopped fine, raw ham chopped 
fine, beefsteak lightly broiled with fresh butter, fine scraped beef 
(loin), white bread, potato puree, coffee and tea largely diluted with 
milk. 4. Roast chicken, roast pigeon, roast venison, roast beef (cold), 
veal (choice), macaroni, rice gruel, spinach (finely chopped), aspara- 
gus, steamed apple, the lightest white and red wine. Food should 
be taken every three or four hours in small quantities, never in a 
state of fatigue, and the patient must stop short of satiety. Small 
quantities of alcohol aid digestion ; champagne or other effervescent 
forms hinder it, still more so do fruit wines. Beer may be taken in 
small quantity some time after meals. Caviare, sardelles, ham and 
smoked meats excite the appetite through creosote; with the devel- 
opment of much gas, vegetables, fresh bread, all fruit and milk must 
be avoided. Bad breath is obviated by avoiding fresh albumen. 
The meat in these cases should be smoked. 

Regular habits of rising and going to bed, exercise in the fresh 
air, morning baths, cultivation of a cheerful disposition, are adju- 
vants. The mineral waters, especially at their sources, are most 
valuable. They may be substituted at home by artificial products, 
common salt, Carlsbad salts, the carbonated waters of the soda 
fountains, Vichy water, which in cities may be decanted into bottles 



396 TREATMENT OF DISEASES OF THE STOMACH. 

at the drug store and served at home like beer. As stated already, 
no drug equals dilute hydrochloric acid, gtt. x.-xx. in a wineglass of 
cold water before or after meals. Pepsin may help; still better is 
pancreatin, gr. xv.-xxx. after meals. The physician must have the 
help of an honest apothecary with these preparations. Of bitters 
choice may be made of quassia, gentian, calamus, absinthe. Two 
excellent bitters are fluid extract of condurango bark gtt. x.-xv., 
and the tincture of rhubarb 3 ss.-i. diluted. Creosote is one of the 
finest contributions of modern therapy. It shows its virtue in that 
most obstinate of all forms connected with and based upon tubercu- 
losis. It maybe given in capsule gtt. i.-ij., or, better, with equal 
parts of tincture of nux vomica, rhubarb, or gentian ; and the dose 
may be of the mixture gtt. v.-x. in wine (sherry), or whiskey and 
water equal parts, a teaspoonful to each drop. An appetizer of 
much promise in bad cases of gastric catarrh, tuberculosis, Bright's 
disease, etc., is orexin. Care must be taken to secure the basic 
orexin, as the acid form burns the stomach. It is given best in 
capsules, gr. v. twice a day with much fluid. The appetite sets in 
sometimes after the first dose and continues, or again only after sev- 
eral days, or only after each dose. It acts by exciting the flow of 
hydrochloric acid. Sometimes it produces a ravenous appetite; 
sometimes it fails (Penzoldt). Vomiting may be checked best by irri- 
gation with the stomach tube, which is always the sovereign remedy, 
by small doses of chloral in peppermint water gr. ij.-v., by tincture 
of belladonna gtt. x., or chloroform gtt. v.-x. on sugar, or cocaine or 
morphia, or morphia with atropine. Morning vomiting is brought 
under control best by atropia gr. i. — 3 i. solution, dose gtt. ij.-v. at 
bedtime. Vertigo is relieved by chloral gr. v.-xv. 

Surgical measures are always called for in desperate cases. Bill- 
roth, in the review of his one hundred and twenty-four cases of 
operations on the stomach and intestine in the past twelve years, 
records a rescue of one-half of all the cases of all kinds. Metastases 
and recurrence took place, of course, in carcinoma, quickly in the 
gelatinous and cylindrical forms, more slowly in scirrhus, but surgi- 
cal intervention gave relief in all cases, showing striking contrast in 
this regard with the cases left to fate. 



CHAPTER III. 

DISEASES OF THE INTESTINE. 
INTESTINAL CATARRH. 

Catarrh of the intestine differs from that of the stomach in 
that, while it is in the acute form more frequent, it is in the chronic 
form less frequent. Catarrh of the intestine when chronic depends, 
as a rule, upon some outside disease. Acute intestinal catarrh is 
perhaps the most frequent of all diseases. It constitutes a large 
contingent of cases of diseases of infancy, where it is encountered in 
its most exquisite expression. 

Pathology and Etiology. — Catarrh of the intestine results first 
from fault in the ingesta. It is the fluid rather than the solid food 
which is most at fault. The chief fault lies with drinking-water. 
Contamination of drinking-water by the discharges of other cases of 
intestinal catarrh, or of other diseases altogether, is the most fruitful 
source of this affection. The disease may in this way assume epi- 
demic proportions. When it shows itself in intense degree, affecting 
also the stomach, it constitutes the affection commonly called cholera 
morbus. Any great fault with the ingesta affects the stomach as 
well as the intestine, to produce the condition commonly called gastro- 
intestinal catarrh. That cholera morbus results often from contami- 
nated drinking-water is proven by the fact that in so many cases the 
discharges contain various micro-organisms. 

Cholera morbus, or that intensely acute expression of gastro- 
intestinal catarrh, is, however, by no means always due to this cause. 
It may result from the other causes of intestinal catarrh. Bad food is 
responsible for fewer cases. Decomposing meats, spoiled fish, unripe 
vegetables, decayed fruits, account for individual cases. Where the 
process of decomposition is not too far advanced it is arrested under 
the antisepsis of free hydrochloric acid in the stomach — a process 
which is continued for a short time in the intestinal canal. The food 
that causes the most irritation is milk. It is unfortunate that the 
food upon which most reliance is placed to substitute the mother's 
milk is the most prone to decomposition. Intestinal catarrh re- 
sults also from toxic cause, as from the action of poisons, arsenic, 



398 INTESTINAL CATARRH. 

corrosive sublimate, or too intense action of the various purgatives. 
Herein is included also the action of specific diseases, typhoid fever, 
tuberculosis, rickets, cholera, dysentery, etc. There may be abnor- 
mal excitability of the sensory or secretory nerves. Influence of the 
nervous system is perceived in cases in which intestinal catarrh re- 
sults from exposure to cold, which, in certain individuals, will always 
produce diarrhoea. Fright may have the same effect. Intestinal 
catarrh results also from disturbances in the circulation. It is found 
in connection with disease of the heart and kings, more especially in 
association with disturbances in the portal circulation, in cirrhosis of 
the liver, etc. The absorption of chemical products, ptomaines, 
toxines, is responsible for certain cases. The intestinal catarrh 
which results from the mere presence of micro-organisms is often 
salutary, in that it secures their expulsion, as in the case of trichino- 
sis. Where peristalsis is easily excited, as in children, the individual 
is protected against disease in this way. Many of us owe escape 
from various infections to the fact that, in the first place, the poison 
is destroyed in the stomach by the gastric juice or is hurried out of 
the intestinal canal by rapid peristalsis. 

Symptoms. — Catarrh of the intestine shows symptoms which dif- 
fer according to the location of the affection. The condition rarely 
extends to involve the whole length of the intestinal tract, but is 
manifest more especially at one or the other extremity. The most 
common expression of intestinal catarrh is diarrhoea. Diarrhoea, 
however, is only a symptom. Under the rapid peristalsis the con- 
tents of the intestine, for the most part digestive juices, are hurried 
along the canal before there is time for their reabsorption. Many 
pounds of these digestive juices are secreted during the day. All of 
it, or nearly all of it, is reabsorbed into the blood. The stay in the in- 
testine is just long enough to secure nuidification and absorption. In 
hypersensitive, irritable states of the mucous membrane the muscu- 
lar coat propels the contents Of the intestine along its course too rap- 
idly to permit absorption. The mass of the discharges, therefore, is 
made up of digestive juices. Catarrh located in the duodenum, 
which exists for the most part in connection with catarrh of the sto- 
mach, manifests itself by the very opposite condition, to wit, consti- 
pation. More or less tenderness may usually be felt in the region 
of the pylorus. There is usually anorexia, frequently nausea, and not 
infrequently icterus. The catarrhal process, which thickens the mu- 
cous membrane, occludes the orifice of the bile ducts. Sometimes it 
invades the bile ducts to lead to the same occlusion, and but very 
slight swelling is necessary to block the bile ducts and necessitate the 
reabsorption of bile into the blood. Hence most of these cases are 
associated with jaundice. Catarrh of the jejunum may not be dis- 



INTESTINAL CATARRH. 390 

sociated from catarrh of the ileum. The known seats of the lesion 
of typhoid fever and tuberculosis in the ileum enable us to exclude 
the jejunum from participation in these affections. In the rare cases 
in which dysentery invades the small intestine its lesions are confined 
about the ileo-caecal valve. 

The point of greatest practical importance is to separate the affec- 
tions of the small from the large intestine in the effort to secure local 
therapy. In a normal state the contents of the small intestine are 
fluid, of the large intestine more or less solid. Copious discharges 
of fluid matter usually come from the small intestine ; smaller dis- 
charges of more solid masses, scybala, come from the large intes- 
tine. Ordinarily the bile is reabsorbed in its passage through the 
small intestine, so that it does not appear in the large intestine. 
Quantities of bile with the stools, which impart to them their green- 
ish color, indicate a discharge from the small intestine, provided al- 
ways the gall ducts be not blocked, in which case, however, there is 
usually constipation. A better evidence of discharge from the large 
intestine is the presence of mucus, alone or coating the exterior of the 
mass. The character of the blood or pus sometimes discharged 
from the stools indicates also the seat of the disease. Blood from the 
small intestine is usually intimately intermingled with the discharge; 
from the large intestine it is either voided pure or it streaks or coats- 
the outside of the mass. In some cases the stools are composed al- 
most entirely of water. The stools of cholera morbus and cholera 
are ninety to ninety-five per cent of water. In these cases water is 
not only voided from the intestinal canal, but is drained also by osmo- 
sis from the blood, and with such rapid exudation as to macerate 
and detach the epithelial cells which appear to constitute the rice- 
water discharges of these diseases. In these cases the stools have lost 
all natural to assume a peculiar odor. Something may be learned 
from the odor of the discharge. An acid odor frequently observed 
in the discharges of childhood indicates for the most part decom- 
position of vegetable food : a putrid odor, decomposition of animal 
food. Naked-eye inspection, more especially as assisted by the mi- 
croscope, gives information as to the degree of digestion. Particles 
of undigested fat indicate, for instance, absence or defective action of 
the bile and pancreatic juice. Undigested muscular fibre shows de- 
fective action of the intestinal as well as of the gastric juice. Parti- 
cles of starchy food, unaffected or but little affected, masses of detri- 
tus, unattached or undigested residue, constitute the condition known 
by the older writers as lientery. Miller called attention to the fact 
that where the catarrhal process is slight the lack of digestion first 
concerns the fats ; where extensive it concerns all kinds of food. 
Bacteria and protozoa abound in the faeces of intestinal catarrh. 



400 



INTESTINAL CATARRH. 



Intestinal catarrh manifests itself also by pain. The pain is 
more acute in accordance with the degree of distention of the intes- 
tine by gas — colic. Colic is often relieved by pressure. Usually, 
however, there is more or less tenderness over the whole region of 
the abdomen. The escape of gas or its wanderings constitute the 
rumble or borborygmi and show increased or irregular peristalsis 
and paretic states. ■ 




Fig. 184.- 
Amoeba coli: 



-Protozoa in the faeces : a, Trichomonas intestinalis; 6, Cercomonas intestinalis; c, 
d, Paramecium coli; e, monadines, living; /, monadines, dead. 



Forms of intestinal catarrh are divided usually into duodenitis, 
ileitis, colitis. A peculiar variety of inflammation, situated at or 
about tjie head of the large intestine at the caecum, is commonly 
known, from the Greek equivalent of caecum, as typhlitis. The dis- 



Fig. 185.— Faeces under the microscope : a muscle fibre ; b, connective tissue ; c, epithelium; 
d, white blood corpuscles ; e, spiral cells ; f-i, various plant cells ; k, triple phosphates. Inter- 
spersed are various micro-organisms (Von Jaksch). 

ease begins, as a. rule, in the vermiform appendix and is often known 
as appendicitis. It is an especial variety of intestinal inflammation, 
which from its frequency and gravity merits especial consideration. 
Colitis is usually described with dysentery. Dysentery is some- 
times a specific colitis, prevailing often in epidemic form. It, too, 
merits especial consideration. Inflammation in the rectum is known 



INTESTINAL CATARRH. 401 

as proctitis. The rectum is also secondarily involved from inflamma- 
tions outside, in connection often with the uterus, or as a localization 
of a septic process, peri- and paraproctitis. The rectum is also a final 
habitat of the tubercle bacillus, which erodes its tissue to form peri- 
neal abscesses and result in fistulse. 

Diagnosis. — The important point in the consideration of intestinal 
catarrh is the recognition of its cause. In acute intestinal catarrh 
this cause is usually obvious in fault with the food. In chronic in- 
testinal catarrh the cause, as stated, is most frequently outside the 
canal. In some cases the mucous membrane undergoes a degenera- 
tion as part process of a widespread affection. This is particularly 
the case in amyloid change, which almost always occurs in connection 
with amyloid kidney and is recognized by the signs of that disease. 
B right's disease not infrequently causes intestinal catarrh through 
mere oedema — a salutary process by which urea is eliminated. Ulce- 
rative processes, as from typhoid fever, tuberculosis, dysentery, carci- 
noma, syphilis, must be always carefully eliminated. They consti- 
tute, as stated, the mass of cases of chronic intestinal catarrh. 

The prognosis depends altogether upon the cause. It is for the 
most part favorable in the acute forms of the disease, but is often 
•excessively grave in childhood. Infants succumb quickly unless 
radical change can be made in the diet. Summer diarrhoea, as it is 
called, is the most fruitful cause of death in infancy. It occurs in the 
second summer, because it is at this time that the child is put upon 
outside food. The chronic diarrhoea which is so fatal to childhood, 
constituting the mass of cases which are called marasmus, is an ex- 
pression for the most part of tuberculosis. All tuberculous patients 
are affected with diarrhoea sooner or later from deglutition of the spu- 
tum. Children never expectorate, so that they show affection of the 
intestine out of all proportion to that of the lungs. 

The treatment of acute intestinal catarrh in infancy is a matter 
wholly of diet. It depends upon fault in diet and is remedied only 
by its correction. The great contingent of cases is furnished by 
children fed with artificial food. The only real remedy is a wet- 
nurse. All other remedies are of secondary importance. No arti- 
ficial food, milk of no animal, will really substitute mother's milk. 
The experiment is usually tried of substituting one form of food after 
another. Sometimes it succeeds ; as a rule it fails, and if a wet-nurse 
may not be obtained, and that quickly, the result is frequently fatal. 
The infants' foods in the market are numerous. Resort must be had 
to them in certain cases. Perhaps most use is made of condensed 
milk, milk with wheat, peptonized milk. The food that should be 
tried first in all cases where mother's milk may not be obtained is the 
imilk of the cow. Failure is experienced often with cow's milk be- 
26 



402 INTESTINAL CATARRH. 

cause it is given in form too concentrated. It should be diluted al- 
ways. In the case of a healthy child the mixture is made, for the 
first three months, two parts water and one part milk ; for the second 
three months, equal parts; from the sixth month on the water is grad- 
ually reduced until pure milk is given. In intestinal catarrh at what- 
ever age, even in advanced life, milk, which still constitutes the best 
food, must be diluted as if for infancy. The dilution may be made 
two-thirds, one-half, one-third, with lime water, with simple water, 
pure, preferably with soda, Selters water, when it may be handled 
by the most delicate stomach. In adults the milk may be substituted 
with, or there may be given in addition, malted milk, beef tea, 
chicken soup, mutton broth, later rice and barley, still later crumbs 
of bread, or zwieback or egg at first diluted as before directed. 
Aside from the specific diseases which require special treatment, all 
irritating ingesta must be first removed. The remedy which best 
secures this effect in either childhood or age is calomel. Calomel 
purifies as it evacuates. It still merits all the praise which has been 
expended upon it in the treatment of these conditions, and has not yet 
found a substitute. It is a remedy which can be given with great 
impunity in childhood and age, though with some reserve in contin- 
ued administration in adult life. It may be given alone or combined 
with chalk. Favorite prescriptions are calomel, bismutlj, and soda ; 
calomel, ipecac, and soda; calomel, salol, bismuth, etc. Luff declares 
that the biniodide of mercury, in a dose of one milligramme every 
three to five hours, cures eighty per cent of cases of summer diarrhoea. 

Catarrh of the duodenum usually calls for laxatives, at the head 
of which, in this case, stands Carlsbad salts, of which there may be 
taken a teaspoonf ul in a glass of hot water two or three times a day 
before meals. Frequent libations of any alkaline mineral water, 
Congress water, Yichy water, are of value. 

In catarrh of the small intestine address must be made to the 
pain, and in this regard no remedy equals opium. Opium stops the 
peristalsis and obtunds the hyperesthesia of the sensitive nerves. A 
fine old combination is that which contains also diluted nitric or 
hydrochloric acid with a little camphor: 

R Tincturas opii gtt. xl.-lx. 

Acidi hydrochlorici diluti gtt. xl. 

Aquae camphorae ad § iv. 

M. S. A tea- to a tablespoonful every two to four hours. 

Broken doses of bismuth gr. v.-xv. alone, or in combination with 
salol gr. iij.-v., or salicylate of soda gr. v.-x., or with a grain or a 
fraction of a grain of ipecac, or with one to three grains of Dover's 
powder, make nice combinations for individual cases. Infants and 
individuals who are extremely sensitive to cold may be protected 



INTESTINAL ULCER. 403 

against attack by warmer clothing, by flannel bandages, or an extra 
undergarment. A tablespoonful of brandy for an adult, with a dose 
of quinine gr. v.-x., or Dover's powder gr. x., taken at night after 
an exposure, to quicken the circulation and dissipate chemical poison, 
will often prevent an attack. Irrigation of the intestine is as effective 
in the treatment of intestinal catarrh as in the case of the stomach. 
The fluid should be introduced in infants with a soft catheter, which, 
warmed and oiled, may be carried into the bowel six to twelve inches. 
The bowel is thus thoroughly washed out once or twice a day under 
careful injection, as in a case of dysentery, where the process is de- 
scribed. The fluid may be medicated, as by a few drops of creosote, 
by the salicylate of soda 3 ij.-Oij., by alum 3 ss.-Oij. Xot a little 
of the good accomplished with injections is due to the absorption of 
water by the drained-out bowel. Warm baths are especially bene- 
ficial in the intestinal catarrh of infancy, and obstinate cases of 
chronic intestinal catarrh are sometimes brought under control by 
small 3 i.-ij. rectal injections of acetate of lead gr. x.- 3 i. An opium 
suppository at bedtime, or a clyster of starch 3 ss. , tincture of opium 
gtt. x.-xv., gives comfort for the night, or repeated after each stool 
checks diarrhoea. A fraction of or a whole teaspoonful of brandy in 
hot water with a little sugar is a valuable aid in childhood. Cholera 
morbus is usually cut short at once in an adult by a subcutaneous 
injection of a quarter of a grain of morphia. 

INTESTINAL ULCER. 

Intestinal ulcer — ulcus intestinorum, entero-helcosis (eXno?, ulcer) 
— represents a solution of continuity in the wall of the intestine, affect- 
ing first, as a rule, its mucous coat. Ulcer of the intestine, like ulcer 
of the stomach, its occasional congener and not infrequent associate, 
is the expression of an insult or injury offered to the intestinal coat 
in its inner exposed surface, or the result of a local occlusion in the 
general blood supply. Hence ulcer of the intestine may be a purely 
local disease, or be the local expression of a general, so-called consti- 
tutional disease. While in many cases the lines differentiating these 
conditions may not be distinctly drawn, as many so-called constitu- 
tional conditions (tuberculosis, typhoid fever, etc.) are discovered to- 
be, at first at least, local processes, the toxic ulcer (arsenic, mineral 
acids) may be taken as a type of the local process acting from within, 
and the syphilitic ulcer as a type of the local process acting from 
without. At the same time it must be recognized of syphilis that an 
ulcer may result from the dissolution or breaking down of a gumma- 
tous mass anywhere in the course of the intestine, or may be the 
effect of infection by extension into the rectum of syphilitic processes 



404: INTESTINAL ULCER. 

about the genital organs, or, lastly, of direct introduction of the dis- 
ease in perverted intercourse (psederasty, coitus heterotopicus). 

Ulcer of the intestine is occasionally, though comparatively very 
rarely, observed also as the result of pressure from within or without. 
Such an ulcer is properly considered of traumatic or mechanical ori- 
gin, as it is induced as the direct effect of mechanical irritation or 
arrest of blood supply. Thus dense masses of inspissated faeces, 
foreign bodies, indigestible residue of food may fret the mucous 
surface into a condition of hypersemia and later absolute ulceration. 
Undue retention, as behind a cicatricial contraction, or an occlusion 
from whatever cause at places where the intestinal tube normally 
offers resistance (at the ileo-caecal valve, sigmoid flexure, etc.), may 
lead to ulceration in the same way. Schonlein has called attention 
to the paralytic condition of the intestinal muscularis in age as a pre- 
disposing cause of mechanical intestinal ulcer ; and Virchow has 
noticed the same condition among the insane, whose intense pre- 
occupation leads to neglect of evacuation of the bowels. Certain 
intestinal parasites, more especially ascarides, are admitted as occa- 
sional causes of ulceration, and more superficial solutions of continu- 
ity in the rectum have been noticed as the result of too frequent or 
too careless use of enemata. 

Curling was the first to call attention to the fact that extensive 
b>urns of the skin are sometimes followed by ulceration of the intes- 
tines. The ulcerative process is almost exclusively confined to the 
duodenum, and is due to erosive action of the gastric juice, continued 
in the intestine upon a tract or section of mucous membrane whose 
blood vessels are blocked with dead blood corpuscles. Whatever the 
cause, the frequency of its occurrence makes it more than a mere 
coincidence. According to Meyer, it is observed most in women, 
and shows its first symptoms in seven to fourteen days after the ini- 
tial burn. 

Aside from toxic and traumatic causes, ulcer of the intestine occurs 
as the result of d}^sentery, typhoid fever, and tuberculosis — diseases 
mentioned in the order of frequency in the production of the process. 
The ulcers of dysentery in the large intestine, and of typhoid fever 
in the small intestine, assume such prominence in these affections — 
having even been erroneously considered at one time as the cause of 
these maladies — that their study belongs to the history of these dis- 
eases. The ulcer of tuberculosis is rather an incident in the course of 
this affection, and is now recognized as the occasional result of direct 
infection by the ingestion of tuberculous milk, but, far more fre- 
quently, of the deglutition of tuberculous sputum. As a rule the 
tuberculous ulcer shows itself late in the course of pulmonary phthisis, 
and is the cause of the obstinate and colliquative diarrhoea which 



INTESTINAL ULCER. 405 

speedily exhausts the patient. Yet cases are occasionally met in 
which numerous or extensive ulcers occur in the intestinal canal 
early in the history of phthisis, before any serious damage has been 
inflicted upon the lungs. The tuberculous ulcer affects, and for the 
most part is confined to, the same structures which form the seat of 
disease in typhoid fever — viz., the solitary and agminated glands of 
the ileum. When the bacilli tuberculosis are conveyed to the intes- 
tine by means of the lymph and blood supply through the mesenteric 
vessels, the resulting ulcer takes the shape of the vascular arrange- 
ment ; that is, the long axis of the ulcer is at right angles to the 
course of the tube. Thus, if sufficiently extensive, the ulcer may be 
circular or form a girdle or ring entirely around the tube. With the 
tubercular ulcer or ulcers are usually found tubercular nodules and 
plaques in the serous coat, which are visible to the naked eye as opa- 
cities or milky deposits beneath 
the peritoneal coat. The glands 
of the mesentery may be at the 
same time so much increased in 
size as to form visible or palpable 
tumors in the abdomen. The 
frequency with which tuberculo- 
sis affects the vermiform appen- 
dix calls for special notice in con- 
nection witht} T phlitis. The ulcer 

of the intestine which is the re- Fig. 1 86. -Tubercular ulcer of ileum (Medical 
Suit Of a Catarrhal process, SO- ^ Surgical History of War of Rebellion). 

called, belongs to the history of chronic diarrhoea and dysentery. 

The true intestinal ulcer per se, which has its analogue in the 
stomach as the gastric ulcer, ulcus rotundum, is due to the same 
cause as in the stomach — viz., to arrest of circulation and erosion by 
the gastric juice. It is a well-established fact in physiology that 
gastric digestion is continued— is, indeed, mainly effected — in the 
small intestine ; hence an arrest of circulation in the small intestine 
is attended by the same result. The fact that this so-called peptic 
ulcer is found almost exclusively in the duodenum speaks most em- 
phatically for this origin of the disease. Arrest of the circulation in 
the intestinal wall may be due to embolus, which, according to the 
observations of Nothnagel and Barenski, is not infrequently found 
in the branches of the duodenal artery ; to infarction, the condition 
so commonly encountered in pyaemia and septicaemia ; or to throm- 
botic occlusion, as seen in amyloid degeneration — a disease process 
which selects by preference the vessels of the alimentary canal along 
with those of the kidney and spleen. 

The duodenal resembles the gastric ulcer in form as well as ori- 
gin. It has the same appearance, in its recent stage at least, of hav- 




406 INTESTINAL ULCER. 

ing been cut out with a punch, shows no inflammation, induration, 
or thickening about its borders at first, and presents the same funnel 
shape with terraced walls, its apex below eccentrically situated, as 
a rule, corresponding to the situation of the artery. It is most fre- 
quently found in the upper horizontal portion of the duodenum, but 
is occasionally, though rarely, seen in the descending portion. In 
the further course of the duodenum the gastric juice becomes grad- 
ually neutralized, so that ulcers situated below the orifice of the gall 
ducts are very great exceptions. In Krauss' collection of forty- 
seven cases but two were found in the lower sections of the duode- 
num. The intestinal, like the gastric ulcer, is usually found single 
or alone, but occasionally two, three, or even four ulcers are encoun- 
tered. According to the tables of Morot a single ulcer is found in 
81.8 per cent of cases, two in 9.2 per cent, and three and four in 4.5 
per cent each. 

Duodenal, like gastric ulcers, are attended with liability to haem- 
orrhage and perforation in equal, if not greater, degree. There is 
also the same tendency to implication of contiguous structures. 
Stich records a case of perforation of the aorta, Eichenhorst men- 
tions the formation of abnormal communication with the gall blad- 
der, and Frerichs a thrombosis of the vena porta, in consequence of 
duodenal ulcer. Lastly, the process of cicatrization may be followed 
by the same disasters as occur in pyloric ulcers in consequence of 
contraction and constriction. Thus the orifices of the pancreatic and 
choledochus ducts may be narrowed or completely closed, or the 
whole lumen of the duodenum obliterated, with consecutive dilata- 
tion of the stomach and oesophagus, as in the case narrated by Bier- 
mer. A very nice question in differential diagnosis, as between py- 
loric carcinoma and pyloric or duodenal ulcer, is sometimes raised in 
this way. In the vast majority of cases it is safe, even in the ab- 
sence of a palpable tumor and without regard to the age of the pa- 
tient, to decide this question in favor of carcinoma. Cases of com- 
plete occlusion constitute the rule in carcinoma and the very great 
exception in ulcer. 

It remains to be said that duodenal is much more rare than gas- 
tric ulcer, in the ratio of one to thirty, and that, unlike gastric ulcer, 
it chiefly affects males. According to the statistics of Krauss, al- 
ready cited, the ratio of males to females is nine to one ; according 
to Trier, five to one. It occurs in greatest frequency between the 
ages of thirty and forty, diminishing with advancing age. 

Symptoms. — Ulcer of the intestines announces itself by symp- 
toms which are, as a rule, much more vague and indefinite than the 
same process in the stomach. In a certain percentage of cases the 
symptoms may be entirely latent, and the cause of a sudden death 



INTESTINAL ULCER. 40? 

be revealed as ulcer only on the post-mortem table. In less severe 
cases the entire symptomatology of intestinal ulcer is grouped un- 
der the term dyspepsia, no characteristic phenomena being manifest 
throughout the course of the disease. 

On the other hand, a very small ulcer may give rise to the most 
dangerous symptoms — hemorrhage and perforative peritonitis — 
which may be even fatal in the course of a few days or hours. 

Among the symptoms that appear with prominence in the course 
of the disease is pa in. Although cases are abundantly on record 
marked by the entire absence of pain, and although pain is by no 
means so universally present as in gastric ulcer, it occurs in the 
great majority of cases. The pain of intestinal ulcer distinguishes 
itself from that of gastric ulcer by being more independent of the 
character of the food or the time of taking it. For the most part it 
occurs in attacks of colic, which are characterized at times by their 
extreme severity, long duration, and obstinacy to every means of 
relief. These attacks occur in paroxysms with complete or only in- 
complete remissions, and are ascribed, as in gastric ulcer, to the ero- 
sive action of the gastric juice upon exposed nerve fibres, the inter- 
vals of relief corresponding to the periods of exhaustion of the nerve 
centres. At the same time, in exceptional cases, a long-continued, 
localized tenderness to pressure may indicate the seat of the disease. 

Palpation may elicit, besides tenderness, points or regions of in- 
duration or intumescence. Such a condition is more especially en- 
countered in cases of tuberculous disease, the so-called scrofula of 
the intestine, the tabes mesenterica of childhood. More localized 
enlargements are occasionally to be felt in the vicinity of the duode- 
nal or other intestinal ulcer in consequence of circumscribed peri- 
tonitis with its resultant agglutinations and adhesions. In this 
connection caution must be exercised not to confound masses of im- 
pacted feces with tumefactions. The history of constipation or the 
administration of a light laxative will generally suffice to remove 
this source of error. 

Anorexia is a symptom of intestinal ulcer as a rule. The loss of 
appetite may amount to a complete aversion to all food or only to 
the more fatty articles of diet. A curious exception to this rule is 
not infrequently seen in the unappeasable hunger of children the 
victims of tuberculous ulceration. The contrast offered in the ex- 
treme emaciation of these patients has been made the subject of 
frequent comment. 

With this loss or perversion of appetite and defective digestion of 
the food the general condition soon begins to fail. Though cases are 
occasionally met in which a bien-etre has been maintained for 
years, or a condition of obesity has been retained, these cases form 



408 INTESTINAL ULCER. 

the exception in the history of intestinal ulcer. More or less emaci- 
ation gradually develops as a rule, and a reduction of the general 
strength that is out of all proportion in its degree to the loss of flesh. 
At the same time the mental condition of the patient suffers a degra- 
dation to the level of the sufferer with chronic dyspepsia. 

The disturbances of digestion which occur in intestinal ulcer pre- 
sent many varieties in degree and kind. Some patients show none 
or but few of the signs, while others run the gamut, so to speak, in 
the semeiology of dyspepsia. Heartburn, eructations, pyrosis, bor- 
borygmi, flatulence, gastralgias, pseudo-anginas, nausea and vomit- 
ing, the familiar phenomena of gastric or intestinal catarrh, attend, 
at some time or other in the course of the disease, most of the cases 
of intestinal ulcer. 

The condition of the discharges demands notice in detail, more 
especially as abnormalities in the evacuations belong among the few 
of the more constant symptoms of the disease. 

Diarrhoea is the rule in intestinal ulcer. The discharges consist 
at first of the undigested food and the digestive juices, which have 
been hurried along the alimentary canal and prematurely evacuated 
on account of the increase of peristalsis caused by the irritation in 
the upper part of its tract. The arrest of the digestive process leads 
to early decomposition of the ingested matters, and thus imparts to 
the discharges an exceedingly offensive odor. While, in exceptional 
cases, constipation may be present, or even obstipation of the bowels, 
the discharges are usually so abundant as to constitute a diarrhoea, 
which in some cases is so frequent or profuse as to become colliqua- 
tive and speedily exhaust the strength of the patient. 

An ulceration situated in the colon or rectum would furnish the 
discharges characteristic of dysentery, while the same process in the 
ileum would show the evacuations characteristic of typhoid fever or 
tuberculosis. 

The most characteristic ingredient of the true duodenal ulcer is 
blood. Ulcer of the intestine constitutes the most frequent source of 
haemorrhage of the bowels, which is sometimes so grave as to take 
life in the course of a few days or hours. The blood from an intesti- 
nal ulcer may be evacuated both by the mouth and the anus, or may 
be retained in the alimentary canal and not appear at all. Such cases 
constitute the condition known and described under the heading of 
occult or concealed haemorrhage, which is recognized by the rapid 
general collapse of the patient. When the blood issues from a duo- 
denal ulcer it is intimately commingled with the contents of the 
alimentary canal. The discharges in such cases are usually black, 
tarry, and more or less fluid ; whereas blood from the colon or 
rectum still preserves its fresh red color and is discharged separate 



INTESTINAL ULCER. 409 

from the faeces or simply coats the exterior. Occasionally cases are- 
met where the blood coagulates in the interior of the intestinal canal 
to form a cast of its lumen or to accumulate in great mass in the 
sigmoid flexure or rectum. In one case in the experience of the 
author such an accumulation was the cause of a very severe tenes- 
mus, which was only relieved by the digital evacuation of large 
masses of inspissated, coagulated blood. 

The presence of pus would indicate lesion of the colon, as typically 
shown in dysentery; for suppuration, at least with any visible pro- 
ducts, does not occur in ulcer of the duodenum. 

Duration — Ulcer of the intestine has no definite duration. As 
in the case of its prototype, gastric ulcer, it may speedily be covered 
with cicatricial tissue and never appear again in the course of a long 
life. But such a course is as unusual as in gastric ulcer. Frequent 
recurrence constitutes the rule in intestinal ulcer, or a partial recov- 
ery with frequent relapse, as in the course of ulcer of the stomach. 
So ulcer of the intestine is not infrequently a lifetime malady, with 
exacerbations and remissions dependent largely upon the prudence or 
imprudence of the patient with regard to diet. It need hardly be 
stated that ulcer of the intestine may terminate fatally, even in the 
course of a few days, from haemorrhage, circumscribed and, later, 
diffuse peritonitis, or may drag out a slow length of years to finally 
destroy the patient with the general symptoms of inanition, hydrops, 
and marasmus. 

Diagnosis. — From what has been said it is plain that ulcer of the 
intestine is often entirely overlooked or may be readily confounded 
with other maladies of the digestive tract. Cases of traumatic or 
toxic origin are generally readily recognized by the history of the 
patient, and tuberculosis may reveal itself by the youth of the indi- 
vidual, the existence of the disease elsewhere, the gradual emaciation, 
the premature senescence — in short, the general signs of the phthisi- 
cal habitus, the meteorism, and perhaps the presence of nodular 
enlargements of the mesenteric glands. A still doubtful case may 
be cleared up with tuberculin. 

The most characteristic symptom of the peptic ulcer is, as stated, 
haemorrhage. But haemorrhage is present in only the minority of 
cases, is, as a rule, occasional and transitory, and is at all times dif- 
ficult of differentiation as to its source. Blood from a gastric ulcer 
may also be voided per rectum as well as per os, and the blood from 
a duodenal ulcer after regurgitation may be wholly discharged by 
vomiting. The absence of vomiting, and the presence — more es- 
pecially the persistence — of tarry evacuations from the bowels, would 
speak for ulcer of the intestine. Dilatation of the duodenum, a con- 
dition of ectasia, closure of the bile duct with consecutive jaundice,. 



410 INTESTINAL ULCER. 

or the presence of fatty stools from occlusion of the pancreatic duct 
(a sign not now regarded of the same value as in the days of Bright) 
would also declare in favor of ulcer of the duodenum. As between 
intestinal ulcer and catarrh or intestinal ulcer and carcinoma, pre- 
cisely the same rules would hold as in the case of the stomach. A 
simple enteralgia would be recognized by its more frequent occur- 
rence among females or individuals of neurotic temperament ; by its 
connection with faults of diet, malaria, or exposure to cold ; by the 
absence of haemorrhage, diarrhoea, or peritonitis. 

Prognosis. — Too much caution cannot be exercised in the prog- 
nosis of ulcer of the intestine ; for in even the cases which run a per- 
fectly mild course the gravest, even fatal, accidents are liable to occur. 
The danger of perforation, in cases of typhoid fever, from a single or 
from one of the few ulcers that may be present imparts one of the 
chief elements of gravity in this disease ; and the same catastrophe 
may occur at any time in dysentery or tuberculosis. The duodenal 
ulcer may likewise have a sudden gravity imparted to a mild case 
by a copious haemorrhage or a peritonitis; and even though the pa- 
tient escape all possible complications, though he recover with the 
surface of the ulcer healed so that the loss of substance is filled in 
with firm cicatricial tissue, the danger of contraction or stenosis still 
remains. The ulcers of dysentery in the colon and of S}'philis in the 
rectum are especially liable to be followed by deformities of this 
Mnd, while the tuberculous ulcer in the ileum not infrequently re- 
sults in a more or less complete stenosis. The ulcer of typhoid fever 
in its cicatrization almost never reduces the size of the intestinal 
canal. 

Treatment. — The most valuable therapeutic means of relieving 
the pain and obviating the dangers of ulcer of the intestine consist in 
the regulation of the diet. The food should be light, easily digesti- 
ble, and during the acute stages of the disease as nearly fluid in its 
consistence as may be. Milk would be the staple article of diet in 
all cases, were it not for the fact that in some cases constipation at- 
tends its too exclusive use. The various soups, without solids, malted 
milk in hot water, starch (sago, arrowroot, tapioca, etc.), may suf- 
ficiently nourish the patient until the healing process shall have 
commenced. Raw beef chopped up and made into an emulsion is 
perhaps the most nutritious and least injurious of any kind of food. 
Bread, potatoes and other vegetables, should be ruled out altogether, 
because of their liability to produce masses of faeces whose inspissa- 
tion may do mechanical damage to ulcers in process of cicatrization. 

Where there is failure in the general strength early resort should 
be had to alcohol, which may be administered, in the form of red 
wine (in preference to white, because of the tannin it contains), wine 



INTESTINAL ULCER. 411 

whey, or, in more serious prostration, of sherry wine, milk punch, 
egg-nog made with good whiskey or brandy. 

In the worst cases, where all food irritates, feeding at the mouth 
may be abandoned altogether for a time, and the strength of the 
patient sustained by nutritive enemata of beef or pancreatic emul- 
sion. Ewald uses as an enema two eggs beaten up with a table- 
spoonful of cold water, to which are added a little starch boiled with 
a half -teacupf ul of a twenty-per- cent solution of glucose, and a wine- 
glassful of claret wine. All enemata should be introduced warm, 
and by means of a long, soft, well-oiled rectal tube, as high up in the 
bowel as may be. Roberts nourished a patient with occluded oesopha- 
gus nine weeks with pancreatized milk, and Donkin supported ten 
cases of gastric ulcer with enemata of plain milk occasionally varied 
by clysters of beef tea, three of them for nineteen days (Stewart). 

The diarrhoea should be controlled rather than entirely checked, 
for fear of the greater evil of constipation. A little bismuth with 
bicarbonate of sodium or oxide of zinc gr. v. may suffice for the 
milder cases, while in the more aggravated cases resort must be had 
sooner or later to opium. 

Constipation is best relieved by careful injections of warm water 
or by the administration of the lighter laxatives — mineral waters, 
seidlitz powders, Carlsbad salts, citrate of magnesia, castor oil, etc. 

Vomiting is combated by ice, soda water, cherry-laurel water, 
chloral with peppermint water, and, in graver cases, by morphia 
hypoclermatically. 

Pain may be relieved by applications of hot water, cataplasms, 
injections of hot water, and, when necessary, by morphia with or 
without belladonna. 

Haemorrhage is checked by ice internally and externally, turpen- 
tine, ergot or preferably ergotin or sclerotinic acid by subcutaneous in- 
jection, and opium. Transfusion, or preferably the subcutaneous intro- 
duction of salt water (4-6 : 1000, introduced by two needles under mas- 
sage), as in cholera, offers hope of rescue from death by loss of blood. 

Patients the victims of intestinal (or gastric) ulcer must maintain 
a guarded diet for months, often for years, after all signs of the dis- 
ease shall have disappeared, as the best prophylaxis against recur- 
rence. Constant vigilance is also required to avoid constipation, and 
the greatest temperance exercised with regard to the use of alcohol. 
Sometimes a course of mineral waters, a sea voyage, or other change 
of life or scene constitutes the best means of avoiding frequent relapse. 

It need hardly be said that an ulcer in the rectum, which is readily 
recognized by its attending tenesmus, calls for local treatment ; and it 
is equally plain that tuberculosis or syphilis demands appropriate 
address. 



412 HEMORRHAGE OF THE BOWELS. 

HAEMORRHAGE OF THE BOWELS. 

General Remarks. — Haemorrhage of the bowels occurs in both 
sexes, though more frequently in the male, and at all ages, though 
more frequently at the middle period of life. In the infant a form 
of it is sometimes considered as a distinct affection under the head of 
melsena neonatorum, and in age it sometimes shows itself as a distinct 
sign of a disease characteristic of age — namely, cancer. According 
to the tables of Bamberger it is caused, in the order of frequency, by 
dysentery, typhus fever, cancer (of the colon), mechanical injury, 
poisons and foreign bodies, ulceration (tubercular, follicular), the 
round ulcer of the duodenum, and aneurism ; last and least frequent 
is the so-called vicarious haemorrhage. 

Etiology. — Haemorrhage from the intestinal canal arises from (1) 
anomalies in the contents of the bowel, (2) disease of the wall of the 
bowel, and (3) from general diseases. 

1. The inspissation of the natural contents of the bowel during 
long-standing or habitual constipation may convert the faeces into 
dense masses, which irritate and scratch the mucous membrane, and 
thus induce haemorrhage directly by simple solution of continuity, or 
indirectly as the result of extreme hyperaemia. Such haemorrhage is 
nearly always slight, streaking or coating the surface of the scybalous 
mass, or being extruded from the anus as a small deposit of blood 
during the last act of defecation ; in which latter case it is found 
mostly associated with haemorrhoids or fissure of the anus. Inde- 
pendent of these conditions, this haemorrhage usually has its origin in 
the lowest region of the large intestine, where condensation of the 
faeces is naturally greatest. 

Foreign bodies in the intestinal canal descended from the stomach 
may also be the cause of haemorrhage in the same way. Thus, stones 
of fruits, bones of fish, fragments of oyster shell, or other substances 
in no way connected with aliment (false teeth, buttons, pins and 
needles, etc.), may be swallowed accidentally or purposely (as by 
children or the insane) to produce intestinal haemorrhage. Drastic 
cathartics (podophyllin, gamboge, etc. ) and poisons (arsenic, mineral 
acids) occasionally act in the same way. Tardieu reports the case of 
a servant to whom was administered, by a charlatan, veratrum with 
coffee, with fatal effect in six days. At the autopsy, made by Amus- 
sat and Reymond, the stomach and small intestine were found filled 
with a dark-brown or black, bloody fluid, but there was no trace of 
perforation, ulceration, or organic disease. 

Under this head mention should be made also of certain parasites 
whose habitat is the intestinal canal, the walls of which they perfo- 
rate. Two varieties, the Anchylostoma duodenale and the Distoma 
hepaticum, are frequent causes of haemorrhage — the former from the 



HEMORRHAGE OF THE BOWELS. 413 

duodenum and jejunum, the latter from the rectum — in hot climates, 
more especially in India and Egypt. 

2. Anomalies in the intestinal walls produce haemorrhage as the 
result of intense hyperaemia (per diapedesin) or of actual loss of sub- 
stance (per rhexin). Copious, even fatal, haemorrhage has thus en- 
sued from dysenteric and typhoid processes (and even without dis- 
coverable cause) where no ulceration or loss of substance could be 
discovered on autopsy ; and this accident is so frequent as the result 
of ulceration in the disease mentioned as to constitute a characteristic 
sign or complication. It must be said, however, that cases of alarm- 
ing or fatal haemorrhage, without apparent cause during life or lesion 
after death, were more frequently reported in the literature of the times 
preceding our more accurate knowledge of pathology and pathogeny >- 
Few clinicians or pathologists would now be content with reports 
made without full knowledge of the history of the case or micro- 
scopic examination of the intestinal walls. Thus, the report before 
the Societe medieale d'Emulation, April 2d, 1834, by Dubois, of a 
young man who quickly died of intestinal haemorrhage five days after 
a severe headache, and on the same occasion, by Guillemot, of several 
similar cases, would awaken the suspicion of masked typhoid fever ; 
and the case of an old man aged seventy-four who died of intestinal 
haemorrhage after four days' diarrhoea, reported by Husson, would call 
for a close examination of the vessels in the intestinal walls. In fact, 
Bricheteau, who reported a case from the Hopital Neckar, was able 
on autopsy to discover a rupture in a small artery of the intestines. 

Embolic processes leading to the formation of ulceration (by pre- 
dilection in the duodenum) are often attended with intestinal haem- 
orrhage, which would be more constantly present were it not for the 
fact that, as in the stomach, the speedy establishment of collateral 
circulation prevents the consequences of complete infarction. 

Besides dysentery and typhoid fever, tuberculosis and syphilis are 
occasional causes of ulceration and necrosis of the intestinal walls 
which may be attended with haemorrhage. Cancer of the intestine 
most frequently affects the rectum, but wherever situated may show 
haemorrhage as one of its signs. 

The local hyperplasia of the mucous tissue which constitutes a 
polypus, and which in children, in whom it most frequently occurs, 
is mostly situated in the rectum, is suspected to exist or is recog- 
nized by the frequent discharge of blood from the bowels. A far 
more grave affection of the intestinal walls, likewise most frequent 
in childhood, is the peculiar dislocation known as intussusception or 
invagination. This condition is so commonly attended with dis- 
tressing evacuations of blood and mucus as to simulate dysentery. 
The strangulation of the intussuscepted mesentery with its vessels 
easily accounts for the haemorrhage in such cases. 



414 HEMORRHAGE OF THE BOWELS. 

A more extensive compression is exercised at times by tumors in 
the abdominal cavity, as by pregnancy, ovarian growths, etc. ; oc- 
clusions in the course of the portal system (cirrhosis hepatis) ; inter- 
ference with the general circulation, as in disease of the heart or 
lungs, with intestinal haemorrhage as a consequence. 

Diseases of the blood vessels themselves, as amyloid degenera- 
tion, aneurism, should not be omitted from the list of factors possi- 
bly productive of this result. 

3. The general diseases attended with haemorrhage from the bowel 
are characterized for the most part by more or less general disinte- 
gration or dissolution of the blood, with the manifestation of haem- 
orrhage in various parts of the body, kidneys, uterus, subcutaneous 
tissue, etc. , the enterorrhagia being an accidental localization, so to 
speak, of the effusion. The most prolific causes of this disorganiza- 
tion are the micro-organisms, which "touch the life of the blood 
corruptibly"; and hence the various acute infectious diseases may 
show in the severer forms haemorrhage from the bowels. Under this 
head may be ranged variola, which boasts even of a haemorrhagic 
form ; typhus, yellow, and malarial fevers ; the forms of nephritis 
marked by uraemia ; cholera, icterus gravis, erysipelas, etc. Disin- 
tegration of the blood or partial dissolution of its corpuscular ele- 
ments occurs also in those obscure affections which constitute the 
group, or are included in the description, of the haemorrhagic diathe- 
ses, as haemophilia, leukaemia, pernicious anaemia, scurvy, of any of 
which enterorrhagia may be a distinct or dangerous sign. 

Melaena neonatorum is the distinct name given to a haemorrhage 
from the bowels which occurs a few hours or days after birth, and 
which is often so profuse as to cause death at once or in a short 
time. In most cases no anatomical lesions can be discovered after 
death, save an intense hyperaemia of the intestinal mucosa, so that 
the etiology of this affection is involved in obscurity. The various 
causes assigned in its production — ulceration of the stomach or duo- 
denum (Bohn), embolism (Landau), fatty degeneration (Steiner), 
premature ligature of the umbilical cord (Kiwisch) — answer only for 
individual cases. Betz reports a case in a family subject to haemo- 
philia, and Trousseau once saw twins thus affected; but that hered- 
ity cannot account for all cases is shown by the fact that it occurs 
mostly in healthy children from healthy parentage. Klebs is in- 
clined to attribute the affection to the action of micro-organisms, in- 
troduced perhaps as the result of puerperal infection; but this cause 
can be assumed in only a small minority of cases — at least but a 
small percentage of cases coincide with puerperal disease on the part 
of the mother. 

The affection is fortunately rare. Eichhorst states that Hecker 



HEMORRHAGE OF THE BOWELS. 415 

observed it but once in five hundred births and Gemich but once in 
one thousand births. According to Billiet the haemorrhage is oftener 
(eight-fourteenths) intestinal, rarer (four-fourteenths) gastric, and 
rarest (two-fourteenths) both. It is almost always abundant and 
quickly repeated, the blood being mostly pure, in clots or masses and 
fluid, though it is sometimes commingled with meconium. It usu- 
ally ceases within twenty-four hours, though it may continue for 
three, five, or more days. Of twenty-three cases reported by this 
author twelve recovered and eleven died. 

Morbid Anatomy. — Haemorrhage from the bowels, being only a 
symptom of very many different conditions, is marked by lesions 
characteristic of the condition in an individual case. These lesions 
are more appropriately described in connection with the various dis- 
eases. Xot infrequently in these cases the intestine is distinguished 
by the absence of any lesion at all. But, from whatever cause, haem- 
orrhage from the bowels, like haemorrhage from any other source, 
shows a more or less profound anaemia of all the internal organs, and 
in more chronic and protracted cases leads to fatty degeneration, 
more especially of the heart. 

Symptomatology. — Haemorrhage from the bowels is usually 
readily recognized by the discharge of blood, either pure or mixed 
with the natural contents of the alimentary canal. The actual seat 
of the haemorrhage may, however, only rarely be recognized by the 
rectal speculum. The colicky pains, borborygmi, or sensations of 
fluids in the abdomen which are occasionally experienced may not be 
relied upon in fixing the seat of the effusion. Should the haemor- 
rhage occur in quantity, or, more especially, should the seat of the 
effusion be low in the intestinal canal, the blood which escapes is 
more or less pure. When the haemorrhage is higher, or when the 
stay of the blood in the bowel is longer, it becomes more or less in- 
corporated with the contents of the bowels or altered by the intesti- 
nal juices, to present a discharge of mushy or semi-fluid consistence, 
of .dark-brown or black color. So-called tarry stools are thus largely 
composed of blood. 

But serious, even fatal, haemorrhage sometimes occurs without 
the escape of any blood at all. Such are the so-called cases of con- 
cealed, occult, or internal hcemorrhage, in which the nature of the 
malady is only suspected or recognized by the general symptoms 
attending the profuse loss of blood. Should the haemorrhage be 
gradual, anaemia slowly supervenes, with hydrsemia and subcutane- 
ous dropsy. Traube reported a fatal case of oedema of the glottis 
from such a cause. Sudden haemorrhage announces itself by pallor 
and prostration, dyspnoea, vertigo, and syncope. Amaurosis, tin- 
nitus aurium, formication, emesis, and, if the disease be high up in 



416 HEMORRHAGE OF THE BOWELS. ' 

the intestinal canal, haematemesis, are the common attendants of 
serious haemorrhage. In the worst cases of sudden effusion the pa- 
tient may present the appearance of complete collapse, and the in- 
testinal canal be found on autopsy distended with blood throughout 
a great part of its course, while no blood whatever has escaped from 
the rectum. In such a case, or with more gradual loss of blood, the 
patient experiences a sense of increasing weakness; the skin becomes 
cold, is bedewed with a clammy sweat; the pulse grows feebler, and 
death from exhaustion more or less speedily ensues. 

Diagnosis. — The presence of blood in any quantity in the stools 
is readily recognized by its coarser characteristics. Ridiculous er- 
rors have been made by mistaking the coloration produced by bis- 
muth, iron, logwood, etc., administered internally, or by coloring 
matters introduced into the discharges for purpose of deception. 
The microscope, Teichmann's test for blood crystals, and in ex- 
tremely doubtful or medico-legal cases the spectroscope, furnish easy 
means of detecting blood in whatever quantity or character. 

It is the cause and seat, rather than the existence, of the haemor- 
rhage that mostly produce embarrassment in differential diagnosis. 
Haemorrhage from the lungs, nose, or stomach is usually readily ex- 
cluded by the absence of any evidence of disease of these organs, and 
the presence of the other symptoms of any general disease attended 
with enter orrhagia makes a diagnosis in most cases easy enough. 
Alterations in the contents of the bowel, the presence of foreign 
bodies, are recognized by the history of the case and by careful local 
examination, while a diagnosis of anomalies in the walls of the bowel 
is usually reached by exclusion. In no doubtful case should local 
inspection or digital examination of the anus and rectum be omitted. 
Treatment. — As in all cases of haemorrhage, the first requisite is 
absolute rest. The patient should at once be put to bed and kept 
perfectly quiet. Many a case of haemorrhage in typhoid fever is 
produced by arising from bed" to go to stool. The bedpan is an ab- 
solute necessity in the management of a case of typhoid fever after 
the second week of the disease. Rest is the chief element in proplrr- 
laxis as well as therapy. 

The most effective styptic in enterorrhagia is cold. An ice 
bladder should be laid upon or suspended immediately above the 
abdomen during the whole duration of the flow. The injection of 
ice water into the bowel should be practised only in cases where the 
haemorrhage is believed to come from the colon, otherwise the 
peristalsis it awakens may only aggravate the danger. Should rest 
and cold fail to quickly check the haemorrhage, resort should be had 
at once to ergot. This remedy, in the form of ergotin or sclero- 
tinic acid, is most effective when introduced beneath the skin. In 



TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 417 

cases of less imminent danger the practitioner may be content to give 
the remedy by the mouth. 

Small doses of the simple or camphorated tincture of opium fre- 
quently repeated speedily arrest contractions of the bowel and at the 
same time feed the brain in threatening syncope. The astringents 
proper — tannic acid or its preparations, acetate of lead, alum, the per- 
chloride of iron — are seldom necessary or advisable, but may be called 
for in obstinate or protracted cases. 

To turpentine have been ascribed from time immemorial specific 
virtues in relief of haemorrhage of the bowels, and its administration 
is still a routine system with many older practitioners. It is most 
effective in large doses — one drachm, with milk or in emulsion, every 
hour or two until the hemorrhage ceases. 

In relief of collapse, alcohol, ether, camphor, and musk are im- 
peratively indicated, with the external application of heat ; and in the 
treatment of the anaemia and hydraemia, the preparations of iron, 
including later the mineral waters which contain it. In the worst 
cases of sudden, alarming hsemorrhage the physician should not fail 
to practise the transfusion of blood, or preferably hypodermato-clysis 
with solutions of salt water. 

Milk, including malted milk, is the best food and drink during the 
attack, and after it for some days or weeks. Chopped or scraped raw 
beef may substitute it later, while all farinaceous foods are to be 
strictly avoided for some time. 

TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

History. — Typhlitis (tvcpXol, blind) — inflammation of or about 
the head of the colon, more especially the vermiform process — is a 
disease of modern recognition. Individual cases have been reported 
as curiosities where foreign bodies or faecal accumulations had ex- 
cited inflammation in this part of the intestine, but it is undoubtedly 
to Dupuytren that the credit is due of having first individualized this 
disease as a separate affection. About the same time, 1827, Longer 
Yillermay published his communications on the diseases of the ver- 
miform process, to be followed in the same year by Melier and Hussar 
and Dance with observations on inflammation of the connective tis- 
sue in the region of the caecum. These affections, which had been 
hitherto described as inflammatory tumors in the right iliac region, 
now received from Puchelt the distinct name perityphlitis. 

Perhaps the most remarkable events in the history of these affec- 
tions since this time are the contributions of Stokes and Petrequin 
(1837) on the value of opium in the treatment of perforation of the 
vermiform appendix; of Albers, who first distinguished the special 
form of typhlitis stercoralis; and of Oppolzer (1858-61:), who set apart, 
27 



418 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

perhaps as an unnecessary refinement in differential diagnosis, a 
paratyphlitis, an inflammation of the post-caecal connective tissue. 
Matterstock (1880) deserves especial mention for having given such 
prominence to anomalies of the vermiform appendix in the etiology 
of the affection ; and Kraussold (1881) has connected his name with 
the therapy of the disease by the boldness with which he expresses 
his convictions regarding the necessity of early evacuation, by inci- 
sion, of inflammatory products, as first practised by Willard Parker 
in 1843. The affection is more common or has been more frequently 
reported in the United States than in foreign countries, and has been 
thoroughly treated by American authors, especially by Fitz (Trans- 
actions of the Association of American Physicians, 1886). 

General Remarks. — Typhlitis, strictly speaking, is limited to af- 
fections of the caecum and its appendix vermif ormis ; perityphlitis 
implies an extension of inflammation to the peritoneal envelope of 
these organs ; while paratyphlitis signifies an involvement of the 
extraperitoneal and post-caecal connective tissues. Both perityph- 
litis and paratyphlitis are therefore secondary processes, though they 
may, in exceptional cases, arise from affections of organs other than 
the caecum, as from perinephritis, psoitis, vertebral caries, or as an 
expression of metastatic processes in pyaemia, septicaemia (puerpe- 
ral fever), typhoid fever, etc. 

Etiology. — Typhlitis and its allied affections or complications 
show especial predilection for the male sex and the period of adoles- 
cence. Nearly three-fourths (seven hundred and thirty-three) of the- 
whole number (one thousand and thirty) of cases of perityphlitis col- 
lected from the literature by Matterstock were males, and this pro- 
portion holds good in infancy and early youth as well as in adoles- 
cence. The greatest number of cases, thirty-three per cent, occur at 
the ages of twenty-one to thirty ; next, thirty per cent, at eleven to 
twenty ; while the ratio gradually decreases toward both extremes of 
life. So the opinion is expressed with singular unanimity by all 
authors that these diseases pre-eminently affect the bloom of life. 

The observation that typhlitis has so often been found to arise 
from disease of the vermiform process has led to a closer study of its 
anatomical relations, and developed the fact that this organ is sub- 
ject to great variation in size, shape, and situation. 

Normally the appendix vermiformis arises from the posterior 
interior aspect of the caecum as a tube of the diameter of a goose 
quill and a length of three to six inches, with a general direction up- 
ward and inward behind the caecum. It is commonly provided with 
a small mesentery, which retains it in its place. Its cavity communi- 
cates with the cavity of the caecum by a small orifice which is at 
times guarded by a valvular fold of mucous membrane, while its free 



TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 419 

closed end terminates abruptly in a blunt point. It is commonly 
found filled with mucus throughout its entire length. The existence 
of this superfluous structure, which is found only in man and certain 
of the higher apes, has given rise to much speculation among the 
anatomists and physiologists, especially of the teleological school, as 
to its possible use. It is now, however, the generally acknowledged 
opinion that the appendix vermif ormis is a relic or rudiment of a sub- 
sidiary stomach in lower forms of life. The head of the large intes- 
tine, which forms almost an additional stomach in the gramnivora, is 
very much reduced in the carnivora, whose food contains but little 
indigestible matter, and is greatly reduced in the omnivora, as in 
man. The vermiform appendix is the shrivelled remnant of the great 
csecal receptaculum of the lower animals. In the orang it is still a 




Fig. 187.— Typhlitis. Ulceration of the vermiform appendix (Kraussold) 



long, convoluted tube, but in man' it is reduced, as stated, to the size 
of a quill three or four inches in length, and is often entirely absent. 

Kraussold, who complains that the vermiform process has hith- 
erto received only stepmotherly treatment at the hands of anato- 
mists and clinicians, undertook a series of investigations which went 
to show how often and what extreme anomalies do occur. In some 
cases the appendix was disposed in an exactly opposite to the normal 
direction, its blind end being turned upward along the ascending 
colon. In one case it was found wound about the ileum ; in an- 
other, spirally turned at its end and lightly adherent to a hernial sac. 
Sometimes it was abnormally long or short, open or closed with a 
valve, cylindrical, saccular, or bulbed, fixed or free, curved or bent 
upon itself at a sharp angle, provided with a short mesentery, and 
sometimes, as stated, it was entirely absent. J 



420 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

But by far the most interesting point connected with this organ 
was the frequency with which it was found the seat of ulceration or 
stricture from cicatrization somewhere in its course, the result of 
dysentery, typhoid fever, syphilis, and more especially of tubercu- 
losis. Clinicians who have been struck with the frequency with 
which typhlitis has occurred in tuberculous subjects find in this dis- 
covery a satisfactory explanation of this remarkable coincidence. 

Normally the vermiform appendix is found filled, as stated, with 
a tough, vitreous mucus, but not infrequently masses of faeces, for- 
eign bodies, intestinal worms, etc. , find their way into it, where they 
^remain innocuous or may excite a dangerous inflammation. This 
fact, in connection with the general uselessness or superfluousness of 
this structure, has led pathologists to distinguish the vermiform pro- 
cess with the significant appellation of a death-trap. 

Two anatomical factors deserve especial emphasis in explanation 
■of the frequent origin of disease in the vermiform appendix. One is 
the existence of the valvular fold of mucous membrane, already 
mentioned, at or near the orifice of the tube in the csecum, the clini- 
cal importance of which was first pointed out by Gerlach. This fold 
is most marked between the ages of three and twelve, and when 
pronounced narrows the orifice to one-half or one-third of the whole 
calibre of the tube. As a rule this fold and the consequent diminu- 
tion in the size of the orifice are but little marked in the first years 
of life and in old age, which accounts for the relative infrequency of 
typhlitis at these periods of life. 

' The second mechanical factor is the deformity caused by the ab- 
normal anatomical position of the organ, either as a congenital de- 
fect or as a pathological change. Matterstock quotes from Zungel, 
who observed, in fifty-nine cases in the Hamburg Hospital, whole or 
partial obliteration thirty times, catarrh and old faecal concretions 
forty-three times, abnormal adhesions twelve times, and actual ulce 
ration (without perforation) eleven times. Toft claims as the result 
of three hundred personal investigations that every third person be- 
tween the ages of twenty and seventy showed the traces of present 
or past inflammation, and that actual ulceration existed in five per 
cent of all bodies examined. Kraussold declares that this percent- 
age is rather too low than too high, and adds that among his pa- 
tients — who were, it should be stated, mostly phthisical — it was re- 
markable how extraordinarily often the whole vermiform appendix 
was the seat of an encroaching ulcer. In a number of cases cica- 
trices or cicatricial alterations were found where typhoid fever or 
dysentery had existed in the previous history. 

Attention should at least be called to a last anatomical factor in 
explanation of the frequency of ulceration and inflammation of this 



TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 421 

structure, in that its walls are so sparsely endowed with muscular 
tissue as to render it unable to empty itself of bacteria or organisms 
of disease which enter it from the comparatively stagnant reser- 
voir, the caecum. 

Constipation is usually invoked as a cardinal factor in the gene- 
sis of typhlitis (typhlitis stercoralis). Speck calls attention to the 
frequency of the disease in East Siberia, where the food, mostly 
vegetable, contains a large amount of indigestible residue. But that 
this condition cannot sufficiently account for the disease in most 
cases is proved by the fact that constipation is more frequent in ad- 
vanced life and among females, in whom typhlitis with its associate 
lesions is more infrequent. For the same reason a sedentary mode 
of life loses force as an argument in its production. Perhaps the 
most efficient cause of the condition is a local paresis of the muscu- 
lar tissue of the caecum, produced by the irritation of intestinal ca- 
tarrh, of disease products, of a faecal' concretion or a foreign body 
— an irritation which may induce first a spasmodic action, and sub- 
sequently, as a result, a partial paralysis or a paresis. The same 
condition may be brought about more directly by the presence of a 
centre of irritation — viz., by reflex inhibition or innervation. Accu- 
mulation and impaction of faeces must then necessarily ensue, and it 
is highly probable that this accumulation occurs in this way as a 
result more frequently than as a cause of the condition. For the 
symptoms of a simple accumulation of faeces (coprostasis) are never 
so severe, at least at the start, as to mark the onset of a genuine 
typhlitis. Xor is there anything in healthy faeces to induce the 
signs of a severe blood poisoning, which so commonly announces the 
advent or course of typhlitis. 

The role of pure mechanical causes cannot be ignored or under- 
rated in true typhlitis, understanding by this term processes which 
commence in the vermiform appendix. For it is the rule to discoA'er 
in the vermiform appendix in these cases either faecal concretions or 
foreign bodies. Hackel and Buhl found concretions of meconium in 
a new-born child ; and faecal concretions, intestinal stones, are far 
more frequently encountered than foreign bodies. In one hundred 
and forty-six accurately observed adult cases recorded by Matter- 
stock, faecal concretions were met with sixty-three times, foreign 
bodies nine times, while in the other cases nothing could be discov- 
ered ; and in forty-nine cases among children faecal concretions 
were discovered twenty-seven times, foreign bodies three times,, and 
nothing abnormal in the remaining cases. ^N"ot infrequently a small 
foreign body acts as a centre of crystallization for faeces, which be- 
come superimposed in successive layers. Hairs, as of the beard, 
sometimes officiate in this way. Among other foreign bodies met 



422 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

with in fatal cases of perforation, independently of faeces, may be 
mentioned round worms (Faber), cherry stones (Paterson), needles 
(Payne), fish bones (Ziingel), gall stones (Hallete), a mass of asca- 
rides (Klebs), buttons (Gerhardt), etc., etc. As already intimated, 
supposed foreign bodies are often found on examination to be nothing 
else than intestinal concretions. As to cherry stones, which are so 
often accused of producing typhlitis, Biermer and Bossard found it 
difficult or impossible to force them into the vermifoi'm process. 

Symptoms. — Typhlitis announces itself in two ways, suddenly 
and insidiously. In adults the disease begins, as a rule, with violent 
jsigns ; in children there is often a prodromatous stage, which may 
last for days or for months before a positive diagnosis can be estab- 
lished. There are in these cases anorexia and vomiting, constipation 
and diarrhoea, colicky pains, mostly concentrated about the ileo-caecal 
region. There is at this time a disinclination to stand or walk, 
a stooped posture or gait, occasionally a light icterus, a feeling 
of formication or paresis in the right thigh. 

In the adult the disease is wont to begin with more tempestuous 
signs. Not infrequently it is ushered in with a well-marked chill, 
upon which immediately supervenes a sharp pain at the affected re- 
gion. A general collapse of strength soon follows, with fever, thirst, 
a husky voice, a coated tongue, vomiting, singultus, and an expres- 
sion of anxiety. The impression of serious illness becomes apparent 
at once. The case early bears the aspect of a grave infectious dis- 
ease. A constant, dull, boring, gnawing, or lancinating pain in 
the right iliac region first excites the suspicion of the physician as 
to the real nature of the disease. In children the pain is sometimes 
felt first in the epigastrium ; in three cases mentioned by Buchner, 
Her zf elder, and Traube it was first experienced in the left ileum. 
There may be at this time no tumor, but there is increased resistance 
to pressure and exquisite tenderness to touch in the neighborhood of 
the caecum. A particular point of tenderness on a line toward the 
umbilicus, two to two and a half inches from the anterior superior 
spinous process, is known as McBurney's point, and is considered 
characteristic of true typhlitis, though with little reason, considering 
the anomalies of the appendix. The whole abdomen may be more or 
less tender and often tumid. If there should be also gurgling from 
displacement of gas, doubt is excited as to the possible existence of 
typhoid fever. In the course of a few days the tumor takes shape. 
A typhlitis stercoralis shows a distention of the whole ascending 
colon, a sausage-shaped tumor, smooth or nodulated, along the en- 
tire right side of the abdomen, with increased resistance also in the 
transverse colon. More frequently in typhlitis, and as a rule in 
peri- and paratyphlitis, the tumor or tumefaction is more localized 






TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 423 

about the head of the colon. Frequently the swelling is so great 
as to be visible as a protrusion or bulging of the affected region. 
Percussion shows dulness, tanquam femoris, in cases of pure typhli- 
tis, whereas in paratyphlitis there is tympanites on light and dulness 
only on deep percussion. Palpation or palpatory auscultation occa- 
sionally, though very rarely, reveals a peritoneal friction sound 
(Gerhard t). 

The third cardinal symptom of the disease is the disturbance of 
digestion, which, as stated, often precedes or attends the first mani- 
festation of the pain and the tumor. Anorexia, nausea, and vom- 
iting — which is, in the last stage of the disease, often substituted by 
singultus — present themselves as occasional or constant signs of the 
disease. Constipation remains, as a rule, throughout the whole 
course of the disease with an obstinac}' which sometimes excites ap- 
prehension of an intestinal occlusion ; or the constipation may alter- 
nate ivith diarrhoea or dysenteric phenomena, more especially in 
the earlier stages. The tongue is, as a rule, heavily coated, or in 
typhoid states is dry, glazed, or fissured, and sordes covers the teeth 
and gums. 

Fever is not a necessary factor in typhlitis, but when present dis- 
tinguishes itself by its irregular range. The pulse is usually accele- 
rated, full, and hard ; the skin is dry and harsh ; the urine is scanty 
and high-colored, and contains, "almost without exception, unusu- 
ally high quantities of indican" (Eichhorst). 

Perforation, when it occurs, is usually recognized at once by the 
signs of more or less immediate collapse, which quickly results in 
death. The abdomen becomes suddenly distended, meteoric over its 
entire surface. The normal hepatic dulness may give place to tym- 
panitic resonance. 

ISTot infrequently perforation occurs as the result of an accident, 
as after a push or blow upon the abdomen (Volz), heavy lifting 
( Volperling) , riding in a wagon (Downs), after emesis (Urban), pur- 
gation (Stokes), enema (Melier), etc., etc. That the slightest agita- 
tion may suffice at times to break down the last barrier of serous 
tissue separating the intestinal and peritoneal cavity is shown in the 
case recorded by With, where fatal perforative peritonitis occurred 
after a fit of immoderate laughter. 

Paratyphlitis distinguishes itself from the other forms of the dis- 
ease by its more insidious character. There is also in paratyphlitis, 
as a rule, less disturbance in the alimentary canal. The ccecum in 
paratyphlitis is mostly empty, or is filled with gas whose pre- 
sence is recognized by tympanitic resonance on lighter percussion. 
On the other hand, paratyphlitis is characterized by the greater fre- 
quency of pressure signs in the right lower extremity. If the 



424 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

subjacent iliac and psoas muscles be implicated the thigh is flexed 
upon the leg in decubitus. Various parcesthesice, formication, 
numbness, pain, and veritable paresis are experienced in the right 
leg. Dysuria, retraction of the testicle, and priapism may also 
occur in this form of the disease. Or pressure upon the iliac vein 
induces thrombosis, with oedema, milk leg. The long- continued 
process of suppuration in paratyphlitis leads also at times to hectic 
fever or pyaemia, ivith slow marasmus. 

In all cases relapses are very frequent, and repeated recurrence 
of the disease constitutes the rule. Eichhorst records the case of a 
court officer who suffered five attacks of paratyphlitis in the short 
space of one and a half years. 

Morbid Anatomy. — The lesions revealed upon the post-mortem 
table show for the most part the ordinary picture of perforative peri- 
tonitis, which is by far the most frequent cause of death. The peri- 
toneum in the vicinity of the perforation is found hypersemic, swollen, 
necrosed, covered with flakes or soft fibrin, or partially agglutinated 
to contiguous structures. The wall of the bowel is very much 
thickened by catarrhal swelling of its mucosa, proliferation of its sub- 
mucous tissue in more chronic cases, oedema of all its coats, or sup- 
purative processes. Not infrequently the mucous tissue is the seat 
of extensive ulceration, which may involve other structures of the gut 
or form an abscess, even as large as a man's head, in its immediate 
vicinity. The abscess may remain strictly localized, or may wander 
to discharge itself into the ileum, csecum, duodenum, and diaphragm 
(Bamberger) with resultant empyema (Duddenhausen) ; colon (Prud- 
homme) ; bladder (Bossard), in which case the fecal concretion became 
the nucleus for a vesical stone ; acetabulum (Aubry) ; inferior vena 
cava (Demaux) ; or peritoneal cavity, the most frequent eventuality. 
Duddenhausen saw in one case a pylephlebitis result ; Von Buhl a 
pylephlebitis and metastatic liver abscess, which condition, Matter- 
stock says, is noted eleven times in one hundred and forty -six autop- 
sies ; and older writers speak of discharges into the pleural sac, into 
the lungs, pericardium, uterus, vagina, etc. A curious case was ob- 
served by Eichhorst in Frerichs' clinic, where pus found escape 
through the umbilicus. So cases of burrowing sinuses with abscesses 
at distant seats, as in the groin or lumbar region, fistulse with con- 
tinuous discharge, and other curiosities, may be found among the 
records by the curious. 

In cases of more acute course the lesions are found centred 
about the vermiform appendix. The most various contortions, adhe- 
sions, or erosions are observed in this structure. Occasionally a con- 
striction occludes the course of the tube, while the distal end is dilated 
into a condition of hydrops. It may be found perforated in one or 






TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 425 

several places. The cicatrices or agglutinations of old attacks may 
be encountered ; it may be cut in two or three pieces (Matterstock), 
or have been entirely absorbed. Kraussold records a case of this 
kind in a colleague who died of typhlitis. Upon the post-mortem 
table no trace of the vermiform appendix could be encountered, except 
a dimple on the mucous surface of the caecum indicating the site of 
its former orifice. 

Diagnosis. — Though sometimes latent for a long time, the recog- 
nition of the disease is usually simple. The age, the sex, the pain, the 
tenderness, the tumor, and the disturbances of digestion sufficiently, 
and for the most part sufficiently early, distinguish the affection. 

Simple impaction of fasces is differentiated by the history of con- 
stipation ; by the feel of the hardened fasces, which form an elon- 
gated, nodulated, sausage-shaped tumor along the entire ascending 
colon, shifting later along the transverse colon ; by the comparative 
slight tenderness ; and by the entire relief which follows thorough 
irrigation of the bowel. Perforation from typhoid fever occurs late 
in the disease. 

Cancer may be eliminated by regard of the age of the patient, the 
slow development and course of the symptoms, and the gradual 
manifestation of its cachexia. 

Invagination is an affection for the most part of early childhood, 
is marked by the sudden appearance of violent symptoms of disturb- 
ance of digestion, vomiting, often stercoraceous, occlusion, diar- 
rhoea, or dysentery, with straining and discharges of blood. 

Gibney reported a case of confusion with hip-joint disease. 

Duration. — Typhlitis with its various complications has no 
definite duration. A case may terminate fatally in the course of a 
few days, or may extend itself over months, or with its effects over 
years or for life. The disease is, as a rule, much shorter in child- 
hood than in adult life. According to Matterstock nearly one-half 
(forty-four per cent) of children succumb to the disease within the 
first three days. Wood records the case of a girl aged ten who died 
in nine hours. The average duration of cases of typhlitis without 
suppuration ranges from fourteen to twenty-one days. The early 
evacuation of inflammatory products by incision and exsection may 
cut the disease short at any time, or exacerbations and remissions 
may manifest themselves for months or years — a condition especially 
liable to occur when burrowing sinuses or fistulas develop, or when 
passive encapsulated abscesses are aroused into activity by some ac- 
cident or indiscretion on the part of the patient. 

Prognosis. — A case of typhlitis stercoralis has no gravity, and 
should terminate or be terminated within twenty-four to forty-eight 
hours after its recognition. Neglected or unrecognized cases, how- 



426 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

ever, are not infrequently fatal from the circumscribed or more es- 
pecially diffuse peritonitis which may ensue. 

Typhlitis independent of faecal impaction is always a grave infec- 
tion, requiring in every instance a very guarded prognosis. 

Every form of typhlitis is more fatal in childhood than in adult 
life, and any case of the disease may present grave complications or 
assume a dangerous form at any time. The greater danger of child- 
hood lies in the greater liability to peritonitis. Most subsequent 
writers confirm this statement, first made by Willard Parker, who 
also remarked that suppurative processes, abscess formation, is more 
common in the adult. The mortality of appendicitis alone in child- 
hood is seventy per cent, in adult life thirty per cent, so that the pro- 
portion of recoveries is exactly the reverse of these figures at the dif- 
ferent periods of life. 

The general adoption of the opium treatment has, however, ren- 
dered ^the prognosis of typhlitis far more favorable — has, in fact, 
reduced the mortality in adult life from eighty per cent, the appall- 
ing figures of the older statistics (Volz), to fifteen per cent, the ratio 
of modern times. 

The means of earlier detection and readier relief of appendicitis 
or evacuation of accumulated pus have also contributed much to re- 
duce the mortality of typhlitis. In 1872 Bull, of New York, had to 
report of sixty-seven cases of perityphlitic abscess collected by him, 
mostly treated without operation, a mortality of forty-seven and 
one-half per cent, while ten years later ISToyes, of Providence, was 
able to report of one hundred cases treated by operation a mortality 
of only fifteen per cent (Pepper). 

The development of fistulae or wandering abscess, the occurrence 
of pyaemia and peritonitis, necessarily aggravate the prognosis of a 
simple case. Perforation is fatal almost of necessity, yet cases are 
not wanting where recovery has occurred even after this gravest of all 
the accidents of the disease. Thus, Patschkrowski reports from Fre- 
richs' clinic a case of recovery after perforation; and Pepper men- 
tions the results of an autopsy made upon an old man who died of 
vesical haemorrhage, in whom he " found that there had, at some 
unknown previous time, been perforation of the appendix." 

Prophylaxis. — The prevention of typhlitis has reference more 
especially to cases of habitual recurrence of the disease in adults or 
to the earliest, prodromatous stage in childhood. The slightest mani- 
festation of pain in the right iliac region should be looked upon 
with suspicion in these cases and absolute rest enjoined at once. 
Since in childhood perforation has occurred in insidious cases after 
so slight an irritation as a laxative or an enema, or even after a 
bath, every provocation of this kind should be avoided. Injunction 



TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 427 

is to be put upon all solid food in all cases, in the inception as well 
as throughout the course of the affection, that the element of copro- 
stasis be not superadded. Adults subject to frequent recurrence or 
relapse may thus avoid the development or aggravation of an intes- 
tinal catarrh, which in other cases of trivial import may become 
dangerous to them. Many cases of typhlitis are doubtless aborted 
at the start by the observance of absolute rest and abstinence from 
food or rigid diet at the start. 

Treatment. — Perhaps no disease requires such careful considera- 
tion of its cause or form, inasmuch as the different varieties call for 
entirely different treatment. A typhlitis stercoralis, for instance, 
requires an exclusive evacuant treatment, whereas a peri- or para- 
typhlitis demands a laparotomy or a treatment that shall put the 
bowel at rest. 

The safest and most effective method of emptying the caecum of 
impacted faeces is by irrigation of the bowels by means of the fun- 
nel syringe devised by Hegar. The patient is put in the knee-elbow 
or face-chest posture, "as Arabs pray," and warm water — which is 
the best solvent for hardened faeces — is allowed to slowly inundate 
the whole tract of the colon. Feeble or reduced patients should be 
supported in this posture until as much water as possible is slowly 
introduced. As a rule a single thorough irrigation will suffice, or 
one or several additional operations may be required to secure the 
desired effect. At the same time broken doses, twenty grains, of 
sulphate of magnesia may be administered every hour or two, not so 
much for the purpose of exciting additional peristalsis as of turning 
water into the intestinal canal from above. The indiscriminate 
habit of purging all cases with Epsom salts, recommended by the gy- 
naecologists, is to be deplored. Very different conditions prevail in 
peritonitis from typhlitis and uterine disease (salpingitis). In the one 
case the bowel is, in the other the bowel is not, affected. Purgation 
which secures osmosis is beneficial in salpingitis, but injurious in 
typhlitis. Where the bowel is itself inflamed purgation is bad 
practice. 

The other varieties of the affection call for opium at the start, 
with the double view of preventing the irregular, spasmodic, or te- 
tanic contraction of the muscular coat and of obviating the danger 
of peritonitis. Opium is not contra-indicated in these cases, even if 
the element of faecal impaction be superadded, as all clinicians are 
familiar with the fact that the bowels will move of themselves at 
times even under its full narcotic effects. The remedy is best given 
in fluid form, as in the tincture, that the dose may be graduated in 
its repetition to secure its full effect without danger ; and it is to be 
remembered that opium, with all its active principles, is of more 



428 TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS, APPENDICITIS. 

value in the relief of peritonitis than morphia alone. The idea that 
opium does harm by "masking the symptoms," as advanced by the 
gynaecologists and surgeons, is unfounded in fact. Opium masks no 
symptom but pain. A careful watch should be kept upon all pa- 
tients treated with large or frequently repeated doses of opium, that 
its toxic effects be avoided. Not infrequently symptoms of poison- 
ing have supervened after a sudden relief of pain, necessitating the 
use of means to keep the patient awake for a number of hours. 

Hot embrocations or poultices applied over large surfaces of the 
abdomen give great comfort to the patient, though the very opposite 
treatment by an ice bag, occasionally shifted or suspended, is more 
agreeable in some cases in the inception of the disease. 

So soon as a distinct doughy sensation or a more marked fluctu- 
ation indicates the development of pus, steps should be taken at 
once to secure its evacuation. In cases of doubt it is best to make a 
tentative exploration with the needle of the aspirator, a large-sized 
needle being preferred on account of the liability of occlusion with 
tissue shreds or other debris. It is quite surprising how rapidly a 
case clears up at times after the evacuation of even only a drachm 
or two of cedematous fluid. More frequently, however, a laparo- 
tomy must be performed and the abscess completely discharged. 
An abscess of more superficial situation, of larger size, or of con- 
tinuous formation is best relieved by free incision. As to the time of 
the operation, the old rule, ubi pus ibi incisio, holds good here as 
elsewhere. An early evacuation of the products of inflammation 
prevents the supreme danger of perforative peritonitis or the forma- 
tion of burrowing sinuses, fistulae, amyloid degeneration, and maras- 
mus. Indurated tumors are sometimes made to soften under the 
long-continued use of cataplasms, and chronic thickenings of the 
walls of the intestine are relieved by general tonics, mild laxatives, 
mineral waters, and gentle frictions with iodine or mercurial oint- 
ments. 

Perforative peritonitis calls for immediate laparotomy, which is 
most successful when not too long delayed, i.e., beyond the third day 
(Fitz). It is, however, not true that laparotomy is imperative in all 
cases of typhlitis. Judgment must be used here as elsewhere. The 
surgeon is too often and too directly followed in certain cases by the 
undertaker. Literature abounds in cases where delay in operation 
(laparotomy) has permitted natural resolution. The frequently and 
rapidly recurrent cases point most strongly to the necessity of exsec- 
tion, though even in these cases it may be a question if it be not 
wiser to suffer a week or two once a year or once in several years. 
Relapses occur also after laparotomy. 

Under no circumstances should a patient affected with typhlitis 



INTESTINAL OCCLUSION. 429 

leave his bed until the last trace of inflammation has subsided, as 
there is always liability to recurrence or relapse. 

INTESTINAL OCCLUSION. 

The writers of antiquity used the terms ileus and volvulus to 
describe many and very varied diseases of the intestine. Volvulus 
has become limited in our day to that peculiar torsion upon its own 
axis which the intestine sometimes undergoes, and which is the rar- 
est form of intestinal occlusion ; while ileus has come to be used as a 
generic term to express occlusion from whatever cause. Miserere 
was a term often used by the older clinicians to express the agony 
caused by this condition. Occlusion of the intestine is naturally a 
clinical expression based upon a gross anatomical state. The state 
may arise from a multitude of causes, but the general result will be 
the same. Occlusion of the intestine necessarily implies a state of 
obstinate and prolonged constipation, usually in this condition termed 
obstipation. Constipation is in itself a relative condition. Accord- 
ing to the teachings of physiology the intestines should be evacuated 
once in twenty-four hours, usually after the break of the fast in the 
morning. Peristalsis is started in the stomach with the ingestion of 
food, to propagate itself along the entire course of the intestinal tract, 
and thus to secure the evacuation of any matter in its lowest parts. 
Evacuation once a day would constitute with some individuals an 
abnormal state ; once every other day, twice a week, once a week, 
are conditions often noticed. Instances are upon record where the 
bowels have not been evacuated for a month, for two months, for 
even three months, without danger. 

1. The tendency of civilization is more and more toward the state 
of constipation. In the first place, life becomes more and more sed- 
entary ; women are constipated almost as a rule. 

In the second place, food is more and more completely digested by 
the cuisine, so that the amount of indigestible residue which may 
alone traverse the whole course of the intestinal canal becomes less 
and less. The life of man becomes also more and more sedentary. 
In-door avocations increase with the advance of civilization. Animal 
food prevails more and more. All these things tend to render the 
bowels sluggish and to produce states of constipation. Preoccupa- 
tion of the mind is a notorious factor. The concentration of business 
and professional avocations diverts nerve force from the intestinal 
canal as well as from the stomach. A fine illustration of this effect 
is noticed in the insane, whose intense preoccupation leads to neglect 
of the natural functions. The large intestine becomes enormously 
dilated in these cases, and stretched so that the transverse colon may 
present a distinct M shape. 



430 INTESTINAL OCCLUSION. 

Hypochondriacs are nearly always constipated. While constipa- 
tion is a relative condition, the state is absolute in an individual, and 
the condition produces distinct discomfort. There is flatulence with 
borborygmi and eructations of gas ; colicky pain from distention ;: 
dyspepsia; at times, from the irritation of accumulated masses, dys- 
enteric phenomena. There is malaise, depression of spirits, not 
infrequently evidence of disturbed circulation in the peripheral 
vessels, acne about the face, haemorrhoids, etc. 

Constipation is usually relieved by appropriate treatment of the 
cause, as by the regulation of exercise, a daily walk or ride on horse- 
back, some kind of gymnastics, massage and faradization of the 
abdomen, enemas ; by address to conditions of the blood, as to chlo- 
rosis or anaemia, by iron, belladonna, strychnia ; in amenorrhcea 
by pills which contain aloes, the official pill of aloes and iron, 
arsenic, etc. Sometimes a teaspoonful of Carlsbad salts in a glass of 
hot water before breakfast will suffice. Then resort must often be 
had to vegetable matters; the simplest are fruits and oatmeal. The 
compound pill of rhubarb, calomel, cascara sagrada, a minute pill 
of podophyllin gr. J-J at bedtime, are effective laxatives; lastly, 
the slow injection and retention until morning of a pint of pure olive 
oil every night. "When constipation becomes obstinate, whether of 
slow or sudden development, it is an obstipation and constitutes a 
marked factor in the history of occlusion of the intestine. An occlu- 
sion may be caused simply by accumulation of faeces, the so-called 
coprostasis, or, when especially marked at the region of the caecum, 
as typhlitis stercoralis. This condition may be usually recognized by 
palpation, which reveals a sausage-like mass in the course of the 
colon, sometimes by touch of the finger introduced into the rectum. 
Occasionally the diagnosis may be established only ex juvantibus — 
that is, by prolonged and repeated irrigation of the bowels in the 
knee-elbow posture. 

2. The occlusion may result also from a foreign body — coins, 
buttons, fruit stone, marbles, teeth, parts of the insertions of teeth, 
hairs, fragments of cotton, dirt, all kinds of foreign matters taken 
purposely or accidentally, especially by children and the insane. 
Most foreign bodies pass. Fragments of oyster shell pass, as a rule, 
in the course of time, creating often much mischief by the way. 
More angular particles, pins or needles, may do destructive damage 
by perforations of the intestine, peritonitis, or the formation of sinu- 
ous tracts, burrowing fistulae, abscesses, etc. The insoluble drugs 
in continuous administration, iron, bismuth, magnesia, may form 
concretions in the intestinal canal. All these substances, however, 
sink into insignificance, so far as foreign bodies are concerned, when 
compared to gall stones, which constitute the most frequent cause 
of intestinal occlusion. Gall stones from one to three inches in 



INTESTINAL OCCLUSION. 431 

length and diameter escape from the gall bladder by process of 
direct ulceration into the transverse colon, and are passed along fit- 
fully, locked up at times in the intestinal sacculae, dislodged under a 
more powerful peristalsis, as a rule to be entirely discharged, but not 
infrequently of themselves, or as a centre for fsecal matter, to be- 
come direct causes of occlusion. 

3. Confining the causes to the bowel itself, there is next to notice 
stricture, as a rule from ulcerative process. Typhoid fever, tuber- 
culosis, and dysentery are the diseases which most frequently pro- 
duce ulceration in the intestinal canal or cicatrization. Typhoid and 
tuberculous ulcers seldom contract the lumen of the bowel. On the 
other hand, dysenteric ulcers frequently narrow the bowel, and al- 
most exclusively, of course, the large intestine. Syphilis and carci- 
noma are perhaps the most frequent causes of stricture. In both 
cases the diagnosis may be made, as a rule, by the introduction of 
the finger. In both cases the lesion is usually situated in the rectum 
and within reach of touch. 

4. Passing next to extrinsic causes, the first condition to be no- 
ticed is that of internal strangulation. In all cases of occlusion 
careful search must be made for the common forms of hernia, in 
the elimination of which it may be necessary to make rectal and 
vaginal examinations. The intestine is sometimes strangulated by 
passing through natural or acquired perforations of the mesentery, 
as, for instance, the foramen of Winslow, orifices in the mesentery, 
meso-colon, omentum. Sometimes a loop of intestine slips under 
the lower edge of the elongated mesentery, low in the pelvis, or in- 
sinuates itself under the pedicle of an ovarian or uterine tumor. 
The most frequent cause of strangulation is that which occurs as the 
result of inflammation, especially of tuberculous character, whereby 
bands of false membrane are formed or abnormal adhesions. A 
knuckle of intestine may slip under an arch formed by adhesion in 
the tip of the vermiform appendix, or parts of the intestine may be 
nipped or compressed by agglutinative inflammation. Under this 
head belong also the cases of obstruction from compression, as 
by tumor, uterine or ovarian, aneurism, retroperitoneal gland, etc. 

5. Volvulus, torsion of the bowel upon itself, implies some de- 
fect in innervation which disturbs the tonicity of the gut. Cases 
have been reported where a volvulus, after being untwisted, twisted 
back upon itself. 

6. The most frequent and strange of all the accidents which oc- 
cur to the intestine are the so-called invaginations or intussuscep- 
tions, a process which has been coarsely likened to a telescoping of 
the gut. This condition implies also some defect in nutrition or in- 
nervation, whereby a ring of the gut becomes paralyzed, to permit 



432 INTESTINAL OCCLUSION. 

the upper portion to slip into its interior. Invagination of the 
intestine is most frequently observed in childhood, one-half of all the 
cases under the age of seven. As a rule the small intestine slips 
into the large, or the ileo-caecal valve leads the way, or the lips of the 
valve glide into the ascending colon and in the extension of inva- 
gination drag down successive portions of the colon. In adult life, 
where the condition is much more infrequent, the ileum may be in- 
tussuscepted into itself, or more rarely the jejunum into the ileum ; 
rarest of all, the ileum is intussuscepted through the ileo-csecal valve. 
In the process of invagination two peritoneal and two mucous coats 
come in contact. The part of the bowel which begins the intussus- 
ception continues always the lowest part, and the extension of the 
process takes place at the expense of the intussuscipient gut, so that 
in the ordinary case the lips of the ileo-csecal valve advance through 
the ascending colon, across the transverse colon at the expense of the 
ascending colon, down the descending colon at the expense of the 
transverse colon, to finally protrude, sometimes in an elongated mass, 
at the anus. If the process were a simple telescoping, with apposi- 
tion of two serous and two mucous membranes and a maintenance 
of the lumen of the bowel, it would not do so much damage. Unfor- 
tunately, however, this is not all of the process. The mesentery is 
dragged in with the descending gut, so that its lumen comes to lie 
against the wall of the receiving gut. Moreover, the vessels in the 
mesentery are blocked. Necrosis sets in and the intussuscepted gut 
sloughs. This process may take place quickly, so that the invagi- 
nated gut may be discharged in twenty to thirty days, sometimes by 
the end of the first week ; or, again, it may be protracted for a year 
or more, with the continuous danger of occlusion or of pyaemia and 
marasmus. Recovery occurs, however, in about half the cases. 
According to the statistics of Brinton, of ever}^ hundred cases of in- 
testinal obstruction forty-three are cases of intussusception, twenty- 
seven of internal strangulation, seventeen of stricture, five of impac- 
tion of gall stones, eight of torsion or twisting. 

Symptoms. — Besides the constipation referred to, occlusion at 
the intestine announces itself by severe pain. The pain is usually 
paroxysmal in its severity, though more or less continuous — par- 
oxysmal because it exhausts the nerve centres for a time. Violent 
tormina characterize nearly all cases. Tenesmus, with straining at 
stool and the discharge of bloody mucus, is more especially charac- 
teristic of intussusception. Vomiting occurs in all cases. It is usu- 
ally excessive, often stercoraceous, and may with its repetition so 
harass the patient as to entirely prevent sleep. It would seem as if 
nature made the effort to overcome the obstruction by the discharge 
above of a large quantity of fluid matter. The fluid, finding no 



INTESTINAL OCCLUSION. 433 

•egress, must be ejected from the mouth. Vomiting grows in fre- 
quency and severity as the occlusion approximates the stomach. 
Stercoraceous vomiting indicates occlusion of the large intestine. 
Valuable information is furnished by the action of the kidneys. The 
urine is often remarkably reduced, and the reduction stands in re- 
lation to the situation of the block. Occlusion high in the course of 
the canal most markedly reduces the quantity of urine. Various 
explanations have been offered to account for this fact. Barlow 
thought that the scantiness of urine was due to the fact that there 
was left no surface for absorption. Brinton attributed it to the pro- 
fuse vomiting, which discharged the fluids of the body in this way; 
Sedgwick to shock, which is most marked in cases of high occlusion. 
Valuable information may be at times derived from the discovery of 
indican in the urine. In cases of high occlusion the amount of in- 
dican is increased — that is to say, the indican does not undergo the 
subsequent changes which eliminate it from the bowel. Indican 
reveals itself sometimes by the blue color of indigo, which may be 
especially observed in decomposing urine. More frequently the color 
of the urine is normal and the indican must be disclosed by chemi- 
cal test. To a quantity of urine in a test tube is added an equal 
quantity of fuming nitro-muriatic acid, and to this fluid three, or at 
the most four, drops of a concentrated solution of chlorinated potash, 
whereby the deep-blue color of indigo is produced. A few drops of 
chloroform added to this mixture, which is then gently agitated, 
carry the blue color with a deposit of the chloroform to the bottom 
of the tube. 

The condition of the abdomen itself furnishes the next infor- 
mation. Distended over its whole course and markedly tympanitic 
everywhere means usually occlusion in the course of the large intes- 
tine. Distentions limited more particularly to the upper region of 
the abdomen, with collapse of the lower region, indicate occlusion 
of the small intestine. The percussion note, the discovery of 
masses, solid or gaseous, by palpation, indicate to some extent 
the situation and character of the lesion. 

The diagnosis of the existence of an occlusion is, as a rule, suffi- 
ciently easy. Occlusion must be separated from typhlitis, coprosta- 
sis, and peritonitis. Typhlitis shows a circumscribed mass in the 
region of the caecum, with at times symptoms of pressure in the 
right lower extremity. Sooner or later an abscess may be discov- 
ered in the course of the disease. Coprostasis is relieved by irriga- 
tion or by hydragogue laxatives. Peritonitis shows fever, dulness 
to percussion at the sides of the abdomen, pain in micturition, ab- 
sence of faecal vomiting. The cause of peritonitis may often be dis- 
covered. 

28 



434 CANCER OF THE INTESTINES. 

The discovery of the cause of occlusion is unfortunately more- 
difficult. Age, gradual development, cachexia, may speak for can- 
cer, which may be recognized by the touch in the rectum or by pal- 
pation of the surface. Previous attacks of jaundice in females past 
the meridian of life speak for occlusion from gall stones. A pre- 
vious attack of dysentery may lead to the discovery of stricture. 
The injection of water into the colon may locate the stricture. The 
depth to which a rectal bougie may be introduced may also furnish 
information. 

It is easy to multiply words in the differential diagnosis of occlu- 
sion of the intestine. No field of medicine is more obscure. Diag- 
noses which are made by guess or which are based upon statistics 
fail oftener than they succeed in an individual case. 

The prognosis is always grave and takes color wholly from the 
nature of the lesion. 

Treatment. — Laxatives in .the early treatment of the condition 
may not be pushed too far. " It is easier to untie a knot," Leichten- 
stern says, "by gentle than by forcible means. Forcible means 
often make it tighter/' Purgatives may lacerate the bowel and pro- 
duce fatal peritonitis. An intussusception may at times be over- 
come by the injection of water or air. A stricture may be dilated 
with the bougie. The contents of the stomach may always be dis- 
charged by the stomach tube. This process prevents extreme ten- 
sion, lessens peristalsis, puts the intestine at rest, and favors the 
chance of recovery where recovery is possible. This method, which 
is officially known as KussmauPs, was really first used, practised, 
and published in Cincinnati five years before the report of Kuss- 
maul's cases. 

The classical treatment of occlusion is the administration of 
opium in doses which put the bowel at rest. Opium is given pre- 
ferably in the form of tincture, and close watch is kept upon its ef- 
fects. Hot applications are usually made to the surface. 

Radical treatment resolves itself into a question of laparotomy, a 
question which may be decided only by a consultation of physicians 
in an individual case. 

CANCER OF THE INTESTINES. 

The intestine is one of the rarer seats of carcinoma. It is af- 
fected, in fact, in but four to eight per cent of all cases of cancer. 
The disease is four times more frequent in the large than in the small 
intestine, and is seated in the rectum in eighty per cent of all cases. 
It is next most frequent at the flexures of the colon. The cancer is 
commonly primary, and subsequently invades the peritoneum, mesen- 
tery, and retroperitoneal glands, or sends a metastatic deposit to the 



CANCER OF THE INTESTINES. 435 

liver. Sometimes this relation is reversed: the disease of the intes- 
tine is secondary to that of the liver. 

The form is usually scirrhus. Colloid comes next, and colloid 
cancer has been recognized in matter in the faeces before the devel- 
opment of symptoms (Charon, Ledegank). Sarcoma is still more 
rare. Lympho-sarcoma may extend to the rectum from neighboring 
lymph glands, and melano- sarcoma or carcinoma may develop in the 
intestine (only in the rectum) by metastasis from the eye or skin. 

Scirrhus of the rectum constitutes, as stated, the most common 
form. The deposit is, as a rule, more or less circular. It forms an 
encroaching ring which constricts, finally occludes, the lumen of the 
gut. Peripheral extension gives rise to agglutinative inflammation, 
which finally converts contiguous structures into an indurated mass. 
Ulcerative processes, degenerations, and dissolutions bring about the 
same destructive changes as at other seats. Cancer is rare before 
forty, and occurs in both sexes with equal frequency. 

Symptoms. — The disease develops very insidiously, and frequently 
exists for months unrecognized. Disturbances of digestion, more 
especially alternating constipation and diarrhoea, the dysenteric 
phenomena, tenesmus, bloody mucus, etc., with gradual but pro- 
gressive degradation of vigor, announce its onset as a rule. Pa- 
tients are commonly treated for chronic intestinal catarrh, or for 
haemorrhoids, or, especially in women, for affections of contiguous 
viscera, especially the uterus and ovaries. The obstinacy of the 
symptoms to treatment leads finally to examination of the rectum, 
with, as a rule, the immediate recognition of the nature of the dis- 
ease. This examination should be made early in cases of chronic in- 
testinal disease, for the reason that cachexia develops later in carci- 
noma of the intestine than elsewhere. The same remark applies 
also to pain. The form of the faeces is often characteristic. Fre- 
quently the faeces are compressed into bands or rods, which alone 
may pass the constricted regions. Tape-like, lead-pencil, sheep- 
balls, are terms applied to matter so compressed. Naturally this 
alteration of form refers simply to anatomical change, which may 
depend upon various other, often outside, causes. Far more charac- 
teristic is the discharge of decomposing, highly offensive matter 
mixed with blood and pus, in which, in rare cases, cancer masses 
themselves may be detected and disclosed. A tumor may tell the 
story to the touch. 

Duodenal cancer would show the same symptoms as cancer of 
the pylorus — to wit, dyspepsia, vomiting, and dilatation, with 
icterus at times in addition. Perforation produces the symptoms 
of more or less sudden collapse. Perforation of the bladder leads to 
the discharge of faeces, intestinal gases, etc., with the urine. 



436 PERITONITIS. 

The diagnosis really rests upon the recognition of the constric- 
tion by the ringer introduced into the rectum, where the disease is 
accessible ; in higher regions of the intestine, by the detection of a 
tumor by palpation. In consequence of the peculiar attachment of 
the intestine the tumor often changes place, may at times disappear, 
-and, in upper regions of the intestine, may be, by pressure, consider- 
ably displaced. The presence of icterus with normal acidity of the 
gastric juice speaks for duodenal rather than for pyloric cancer. 
Faecal masses may be usually removed by copious irrigation. Tumors 
of the kidney and mesentery are situated behind the intestine. Cir- 
cumscribed or inspissated peritoneal exudations, as after typhlitis, 
which most closely resemble cancer, may be often distinguished by 
the age of the patient and the previous history of the disease. Some- 
times a diagnosis may be quickly reached after free irrigation and 
under chloroform narcosis. The use of chloroform is especially of 
value in cases of rectal cancer, where examination is attended with 
pain. An obscure case may justify the excision of a fragment from 
the rectum for microscopic examination. The ratio of frequency 
helps the diagnosis. In eighty per cent of all cases of intestinal 
cancer the disease is in the rectum, in fifteen per cent in the caecum 
and colon, in five per cent in the intestine. The prognosis is fatal. 
The treatment is wholly symptomatic and surgical. 

PERITONITIS. 

Inflammation, usually infection, of the peritoneum. 

History. — Knowledge of the existence of peritonitis as an inde- 
pendent disease dates from the beginning of the present century, 
and is due largely to contributions of Laennec, Corvisart, and Brous- 
sais. Louis, in the first quarter of this century, recognized the fact 
that spontaneous or idiopathic inflammation of the peritoneum is 
very rare. Peritonitis is regarded at the present time as a second- 
ary malady. Cases of so-called primary peritonitis become rarer 
every year, and are accounted for, in the absence of mechanical 
cause or extension of inflammation from contained or contiguous 
viscus, by the action of poisons, micro-organisms or their products, 
circulating with the blood and lymph. 

Etiology. — In the majority of cases peritonitis may be accounted 
for by obvious cause. As commonly encountered, it is most fre- 
quently due to, or consequent upon, inflammation of the uterus and 
its adnexa. Thus, circumscribed peritonitis is a frequent sequence 
of salpingitis (gonorrhoea), and general peritonitis is a common and 
grave complication of the puerperium. The next most frequent 
cause is hernia. Hereupon ensue, in the order of frequency, ulcer 
and cancer of the stomach ; diseased processes of the intestine, es- 



PERITONITIS. 437 

pecially tyjDhlitis, typhoid, dysenteric, tuberculous, carcinomatous 
ulcers of the intestine ; subsequently, diseased processes of other 
organs and viscera, liver, kidneys, spleen, mesenteric glands, etc. 
Aside from the local processes, many of the acute infections develop 
peritonitis. Pyaemia and septicaemia, especially septico-pysemia,. 
scarlet fever, small-pox, erysipelas, and rheumatism may beget the 
disease, usually late in their course. Scurvy, various hsemorrhagic 
maladies, especially Bright's disease, make the peritoneum vulner- 
able. Peritonitis is distinguished, according to its extent, as cir- 
cumscribed and diffused ; according to its intensity, as acute and 
chronic. Peritonitis marked by the rapid accumulation of gas from 
perforation of a hollow viscus is distinguished as pneumo-peritonitis* 
Metastatic deposits from tuberculosis and cancer produce tuberculous, 
and cancerous peritonitis. 

Symptoms. — Pain is the most prominent symptom. It is local- 
ized or diffuse, according to the situation or extent of the diseased 
process. It is usually acute and intense, and is associated with an 
expression of extreme anxiety; the weight of the bedclothes must 
be lifted from the body. The pain is intensely aggravated by motion. 
The action of the diaphragm is hemmed in inspiration. The act of 
urination, especially at its close, is attended with severe pain, 
due to traction of the contracting bladder, paresis of which reduces 
the quantity of urine. The abdomen soon becomes distended, 
meteoric, partly from accumulation of gases, partly from paresis of 
the abdominal walls. The natural dulness of the liver and spleen 
may be substituted by tympanites. This distention of the abdomi- 
nal cavity displaces the thoracic viscera; the lungs may descend no 
lower than the fourth or fifth ribs; the heart is dislocated upward 
and outward. Whether from mechanical cause or toxic effect, there 
is vomiting and singultus, with obstipation of the boivels. Acute 
peritonitis is attended with fever, which may or may not be present 
in chronic forms. The pulse is small and frequent, the respiration is. 
rapid, the features are pinched and anxious, and thus the patient falls 
into rapid collapse. 

The diagnosis rests upon the recognition of the cause. The dis- 
ease must be distinguished from hysterical states with hypersesthesia 
of the abdominal walls. The age and sex of the patient, the absence 
of perception of pain on diversion of the mind from the seat of the dis- 
ease, together with the signs of hysteria — to wit, globus, convulsions,, 
absence of pain on deep pressure — usually suffice to separate the 
maladies. The pain of gall stones and kidney stones, cardialgias 
and colics, is not aggravated by motion and is unattended by 
fever. Pneumoperitonitis is recognized by the rapid distention with 
gas, tympanites on percussion, high stand of the diaphragm, intense 



438 PERITONITIS. 

pain, and rapid collapse. The effusion of peritonitis is distinguished 
from that of common ascites, as withdrawn in either case by aspira- 
tion, by the higher specific gravity in peritonitis, above 1012, and by 
the presence usually of flocculi, or by greater turbidity, etc. Bloody, 
purulent, or ichorous fluid betokens tuberculous or cancerous peri- 
tonitis. Aid is furnished in the recognition of these forms by the 
discovery of outside evidence of tuberculosis or cancer. The diag- 
nosis of tubercular affection, which most chronic cases are thus 
shown to be, is quickly made with tuberculin after the manner 
already described. The author has never yet been deceived or dis- 
appointed with this method in this disease. In one case the diag- 
nosis thus established was verified by laparotomy. The prognosis 
is always grave, but takes color largely from the cause. 

The treatment consists in arrest of the spread of the disease. 
This object is chiefly to be accomplished by rest, with the use of 
opium. Opium with all its constituents is better than any one of its 
active principles. The drug is often given in peritonitis in the form 
of the tincture. The dose may begin with twenty to thirty drops, 
and be repeated every hour or two until it produces its effects. 
There is in peritonitis singular tolerance to opium. Nevertheless 
caution must be exercised, and the pupils and the breathing watched, 
that with the subsidence of pain the patient be not left narcotized. 
Cold, in the form of ice bags, may be applied only at the start. 
Greater comfort is secured later with hot applications. Perforative 
and tuberculous peritonitis justify laparotomy and drainage, which 
may be made more or less continuous with the physiological salt so- 
lution, one drachm to the quart, sterilized and warmed. 



OHAPTEE IV. 

DISEASES OF THE LIVER. 

ICTERUS. 

The liver is the largest gland in the body, and has perhaps the 
most numerous and most varied functions to perform, yet it is sel- 
dom the seat of disease. It is said that the liver is more sinned 
against than sinning. Of the affections of the liver proper — abscess, 
cirrhosis, cancer, echinococcus, amyloid and fatty degeneration — 
very few belong to the liver alone. Abscess is generally a part of 
pyemia or the result of a deposit from dysentery. Cirrhosis occurs 
in consequence of alcoholism and is associated with other lesions 
produced by alcohol. Echinococcus is a parasite ; it may lodge any- 
where in the body, and comes to affect the liver simply because of its 
proximity to the stomach. Fatty and amyloid changes are degene- 
rative processes in consequence of suppuration, syphilis, tuberculo- 
sis, etc. 

Jaundice, which is commonly considered as the sign of disease of 
the liver, is not. an indication of disease of the liver at all. Jaundice 
seldom or never occurs in any of the diseases of the liver just men- 
tioned. When it occurs in these diseases it is accidental. It does 
not belong to them, and the presence of it rather excludes than ad- 
mits them. Jaundice is simply a symptom of occlusion of the bile 
ducts from any one of twenty or thirty causes. The worst kind of 
occlusion of the gall ducts may show a clear skin, and disappearance 
of the tint of jaundice during the existence of this occlusion may be 
a most ominous sign. It may result from non-formation of bile, sup- 
pression and not retention — a condition which speedily terminates in 
death. Jaundice is therefore not a disease; it is only a symptom 
of many diseases. The symptom is, however, entitled to special con- 
sideration, first, because it is so obtrusive as to be recognizable by 
everybody ; second, because it is in its most frequent form produced 
by a distinct cause — namely, catarrh of the bile ducts ; third, because 
in its graver forms it requires a nice study of a great number of dis- 
eases to discover the cause in an individual case. The light of a 



440 ICTERUS. 

great many diseases is focussed upon jaundice; hence jaundice has 
always been considered an interesting symptom to study. 

The question of the production of jaundice outside the liver is 
largely a matter of definition. It has long been claimed that the dis- 
coloration of the skin noticed in certain cachexias, or more especially 
in certain infections and pysemic processes, etc. , constitutes a particu- 
lar form of jaundice whose cause was located in the blood. It was 
assumed that this so-called haematogenous jaundice existed inde- 
pendently of any affection of the liver, and lines were drawn by 
which distinction could be made between hcematogenous and hepa- 
togenous jaundice. The conditions could never have been brought 
in the same consideration, were it not for the fact that the coloring 
matter of the blood is nearly identical with that of the bile . For cases 
of hsematogenous jaundice are due to disintegration of blood corpus- 
cles and liberation of coloring matter. In these cases there is no ques- 
tion of decolorization of the f seces or colorization of the urine — condi- 
tions requisite to constitute a true jaundice. Consequently the sepa- 
ration of hsematogenous from hepatogenous affections has little or 
no real practical interest. When, in the course of the infections or 
poisonings, the coloring matter of the bile is shut off from the intes- 
tine, to be reabsorbed and excreted by the urine, true icterus has 
occurred. 

Icterus neonatorum is always a true icterus. It shows itself in 
nearly all cases of enfeebled children. Plump, healthy, robust in- 
fants at birth maintain a reddish hue or have it substituted by the 
tints of healthy flesh. Infants not so strong have the reddish hue of 
birth substituted often by yellowish tints of the skin and mucosae. 
The coloration passes off in the course of a few days or weeks. 
Should it, however, persist longer than two or three weeks, it as- 
sumes a deeper hue, marasmus sets in, fever, with grave nervous 
symptoms, and there is presented the picture of icterus gravis. The 
light, canalicular catarrh or occlusion by inspissated mucus, which 
causes the milder forms, has now been substituted by organic change 
which has led to complete atresia of the bile ducts — a condition which 
is sometimes congenital. . 

History. — Jaundice comes from the French word jaune, yellow. 
The Germans call the disease, from their own word for yellow, gelb, 
Gelbsucht, the yellow disease. The technical is the Greek term, 
icterus. The Greeks called icterus a disease. Aretseus derived 
the word from certain yellow-eyed, four-footed terrestrial animals 
called iktides. Pliny derived it from a bird called icterus, the sight 
of which cured the patient but killed the bird. This bird is now 
believed to have been the golden oriole. Suidas takes it from iHtivoS y 
a kite which has, according to De Haen, yellow eyes. The Romans 



ICTERUS. 441 

called it morbus regius, from the yellow color of gold, the rex me- 
tallorum. 

The bile played a most important part in ancient pathology. 
The Grecian fathers had many varieties of bile. Aretseus spoke 
of white and black bile. Icterus albus, icterus ruber, icterus cceru- 
leus, were names for chlorosis, erythema, and cyanosis. The bile 
flowed about the body curiously in ancient pathology, to account 
for many diseases. It was especially responsible for mental dis- 
eases and depressions. Melancholia means black bile ; hypochondri- 
asis refers to the liver " under the cartilage." 

Symptoms. — The color of the skin varies in all degrees of in- 
tensity in jaundice, from a light, almost imperceptible tinge to a 
deep-mahogany hue. Once distinctly manifest, it varies in shade, 
but preserves its main color throughout the disease. In lighter de- 
posit it is most manifest about the forehead, the roots of the hair, so 
that it may escape recognition in a man with his hat on in the street. 
The tint is diffused over the body, but is most marked on the flexor 
surfaces. The bile is deposited also in the various mucosa?, but the 
tint is hidden by the deeper color of the blood, to become manifest 
only under pressure which removes the blood, or in thin mucous 
membranes. It may be seen always in the conjunctiva, and, though 
invisible on the lips, shows itself on the hard and soft palate. 

The cause of jaundice is occlusion of the bile ducts. In conse- 
quence of this occlusion the gall bladder and liver become at first 
distended, while the bile is absorbed by the blood and lymph vessels 
to be distributed over the body. It is soon visibly present in the 
urine, which, too, varies in every shade in correspondence with the 
amount of coloring matter it may contain. A true icterus alivays- 
stains the urine, and the diagnosis of the condition rests largely 
upon this fact. The deeper color of the urine becomes apparent 
at a glance. Agitation of the vessel containing it shows a foam, 
persistent and distinctly colored. Spread in a thin layer over a porce- 
lain plate and stroked with a glass rod dipped in fuming nitric 
acid, it shows a play of color, an iridescence from oxygenation. 
The test is usually made by pouring a small quantity of nitric acid 
into a test tube and adding to it one or two drops of fuming nitric 
acid. A layer of the urine is let fall upon the side of the glass 
from a pipette. When there is much bile pigment the surface of 
contact of the two fluids shows a ring of green, violet, and red. A 
smaller amount of bile is detected by filtering the urine and pouring 
upon the filtrate a mixture of nitric and nitrous acids, whereby the 
colored rings form as before. There are finer tests, but these suffice 
for all clinical purposes. Pettenkofer's test for bile acid, which 
consists in adding a solution of cane sugar 1 : 500 and a trace of 



442 ICTERUS. 

concentrated sulphuric acid to the urine, whereby a violet- red color 
is shown, is of but little value. The color is clearly exhibited only 
when the bile acids have been isolated. The detection of bile acids 
in the urine has, anyhow, but little diagnostic value. Small quanti- 
ties can be detected in normal urine. 

Occlusion of the bile ducts shuts the bile off from the intestinal 
canal ; consequently the fceces lose their color, to become lighter. 
Moreover, under the exclusion of bile the fats are no longer digested. 
They appear, therefore, pure or partially decomposed, to impart their 
own color to the stools ; hence in a case of complete occlusion the 
stools assume a putty -like appearance and consistence. Watery 
stools almost never show any of the ingredients of bile. The water 
of these stools comes from the blood. True jaundice implies, there- 
fore, a coloration of the skin and mucous membranes, also dis- 
tinctly of the urine, and a decolor ization of the stools. This col- 
lection of signs protects against deceit and simulation. Where the 
face has been colored, as by saffron or a turmeric, the color may be 
removed with soap or with a chlorine solution or chlorinated lime. 
The mucous membranes show no tint and the urine is not discolored. 
When the urine is discolored, as by rhubarb and santonin, the color 
will be converted into a deep-red hue by an alkali, which will only 
make browner the urine of jaundice. Moreover, in these cases the 
stools show no absence of color. The real secretions of the body — 
tears, saliva, sweat, milk — are never colored, or only so rarely as 
to constitute curious cases. Peculiar yellowish deposits, which may 
assume something of tubercular aspect, show at times on the skin 
in protracted cases, at first in the eyelids, later over the face and 
the rest of the body, to constitute the condition known as xanthe- 
lasma. Yellow vision, xanthopsia, is a much more infrequent curi- 
osity. 

The accumulation of bile in the blood, and the effect of its con- 
tact with the nervous system, produce a distinctive train of symp- 
toms aside from the coloration of the skin. In rather more than 
half the cases the sensitive nerve fibres in the skin are irritated 
to produce itching. Itching occurs in jaundice in sixty-eight 
per cent of cases, and exists in all grades of intensity. It is at 
times so severe as to excessively harass the patient and exhaust the 
strength from want of sleep. It shows itself, as a rule, most in- 
tense on the palms of the hands and soles of the feet and between 
the toes, and may extend to involve any surface of the body. It is 
usually worse at night, and is, as a rule, when it shows itself, so 
severe as to call for special treatment. The spirits are depressed. 
More or less mental hebetude and dulness belong to jaundice. 
There is also a train of dyspeptic symptoms, in connection more 



ICTERUS. 443 

especially with flatulence and constipation, which belongs to the 
condition. The pulse is often reduced in frequency to fifty, forty, 
thirty strokes in the minute. Frerichs counted twenty-eight in one 
case and twenty-one in another. The reduction is ascribed to the di- 
rect action of the bile salts upon the ganglia in the heart. There is, 
along with the dulness and depression of spirits, more or less drow- 
siness, a tendency to sopor, which in a bad case deepens into coma. 
The urine usually shows albumin as well as bile ; irritation of the 
bile pigment and salts may excite nephritis. There may be found 
in the urine of jaundice occasional hyaline casts. 

"Where the condition continues and the occlusion becomes per- 
manent the symptoms show greater gravity. From lack of diges- 
tion of fats and other foods there sets in a gradual marasmus, and 
patients who have been jaundiced for many months or years more 
or less progressively emaciate. There is with this emaciation corre- 
sponding loss of strength, manifest in the force as well as in the fre- 
quency of the heart's action. CEdema of the ankles and dropsy 
may later supervene. The gravest symptoms show themselves on 
the part of the nervous system. Stupor, convulsions, delirium, 
coma, occur toward the last. 

Diagnosis. — Jaundice being only a symptom, the question arises 
at once as to its cause. Jaundice alone indicates, as stated, simply 
occlusion of the bile ducts. What causes the occlusion? Recent 
cases, more especially in the young, are accounted for by simple 
catarrhal swelling of the mucous membrane. The bile flows un- 
der very light pressure; gravity and the vis a tergo force suffice to 
secure its discharge. A slight swelling of the mucous lining in the 
bile ducts will shut off its escape. The inflammation begins often in 
the stomach, to extend into the duodenum and involve the orifice of 
ihe bile ducts. Many cases are, therefore, expressions of simple gas- 
tro-duodenal catarrh. More frequently catarrhal inflammation af- 
fects the bile ducts themselves, and may extend from the orifice of 
the common duct in the duodenum to the gall bladder on the one 
hand and to the lobes of the liver on the other. 

The bile ducts are blocked by a swollen mucous membrane, and 
more especially by plugs of inspissated mucus, which, in conse- 
quence of bile, is dammed back in the liver or gall bladder. The gall 
bladder swells to present a pcdpable tumor at times, which may 
give rise occasionally to a deep-seated sense of fluctuation. The liver 
itself is enlarged, though, as a rule, not to any very great degree. 
W 7 ith the absorption and distribution of bile over the body the liver 
is wont to become subsequently reduced in size. The bile in the gall 
bladder becomes wholly absorbed, to be substituted by pure mucus, 
so that the contents of the gall bladder may assume something of a 



444 



ICTERUS. 



gelatinous consistence and water-like clarity. This is the common 
form of catarrhal jaundice, which presents itself frequently in the- 
young and disappears in the course of two to six weeks. 

The next most frequent cause of occlusion is impaction of a gall 

stone. The stone may be wedged in 
the common duct, or wedged in the 
neck or duct of the gall bladder in 
such a way as to make pressure upon 
the common duct. Cases are on re- 
cord where the jaundice has disap- 
peared while the impaction and occlu- 
sion remained — cases in which agglu- 
tinative inflammation has taken place 
between the gall bladder and the small 
intestine, with subsequent perforation 
and escape of bile. 

The gall ducts are occluded next 
by outside pressure, as by carcinoma 
of the stomach, liver, pancreas, omen- 
tum ; sarcoma or other affection of 
lymph glands; by the cicatrization of an ulcer in the duodenum, or in 
the course of the bile ducts themselves; by all kinds of tumors in the? 




Fig. 188. — Distended ductus chole- 
dochus : probe a passed from empty 
gall bladder into distended duct ; probe 
b from ductus choledocbus ioto hepatic 
duct (Frerichs). 




Fig. 189.— Dilated bile ducts with thickened walls under pressure from cancer of pancreas;, 
smaller openings of hepatic veins, surrounded by cells deeply stained with bile (dark shading). 

abdominal cavity; by abscess from" caries of the vertebrae; by aneurism;: 
by various causes, which must be worked out in an individual case~ 



ICTERUS. 445 

The prognosis depends upon the cause. It is favorable in catar- 
rhal jaundice, not unfavorable in gall stones, which may at least be 
exsected, comparatively unfavorable in ulcer, absolutely unfavorable 
in cancer, and dependent in cases of abscess, echinococcus, syphilis, 
cirrhosis, when it occurs in the course of these diseases, upon the 
direction or extension of these processes. Occlusion from swollen 
lymph glands may be entirely relieved with absorption of these 
glands. 

The treatment of catarrhal jaundice consists in the administra- 
tion of gentle laxatives, whereby states of hypersemia, catarrh, at 
least of the duodenum, may be largely relieved. A sort of routine 
practice consists in the administration of Carlsbad water, or a tea- 
spoonful of the Carlsbad salts in a glass of hot water, before break- 
fast. Stadelman has lately shown that alkalies in small quantity 
have no effect upon the flow of bile, and in large quantity hinder it, 
so that the known virtue of the alkalies must consist in the increased 
alkalescence of the blood, whereby the bile is made more fluid. Rhu- 
barb, aloes, tamarind, are various laxatives recommended. The diet 
must be simple. There is naturally an aversion to fats, which should 
be avoided altogether. The food should be mainly vegetable — this 
food is, indeed, chiefly craved by the patient — with abundance of 
drinks, more especially carbonated drinks, Apollinaris, Vichy, Sel- 
ters water, etc. The treatment consists in the support of the patient 
until the catarrhal element shall have subsided or the plug of mucus 
which blocks the tubes shall have been discharged. Gerhardt pro- 
posed to discharge this plug by faradization of the gall bladder, 
and successful cases have been reported, as exceptions, however, 
to the rule. It has been recommended also to express the obstacle 
with the hands, to seize the gall bladder and literally squeeze out 
its contents. This procedure is for the most part impracticable, as 
the gall bladder may not be seized in this way, or dangerous when it 
may be seized, because of friability and possibility of rupture. Much 
safer and more effective is the plan proposed by Krull. This method 
consists in the injection into the bowel of one to two quarts of 
cold water every morning before breakfast. The temperature of the 
water should be 59° or 60° F., and may be increased to 65° or 68° in 
the course of subsequent treatment. Usually the water is discharged 
in five to ten minutes. The rationale of the treatment is ascribed to 
reflex contraction, whereby the gall bladder extrudes the plug of 
mucus which blocks its calibre. The injection must be repeated 
every day. The desired effect is sometimes accomplished after the 
second or third treatment, of tener not until after the sixth or eighth 
treatment. Whatever the explanation, the treatment is certainly 
successful in a very respectable contingent of cases. Sometimes it 



446 CHOLELITHIASIS. 

causes colicky pains, and in delicate or sensitive persons it may even 
produce a chill, in which case, upon the subsequent occasion, the 
water should be warmer. The treatment is so simple, and the natu- 
ral course of the disease is so protracted, that it should always be 
given trial first. 

CHOLELITHIASIS. 

Cholelithiasis {x°^V> bile? \i$o<s, stone) ; gall stones. — The most 
frequent, severe, and dangerous disease connected with the liver is 
that produced by the formation and discharge of gall stones. 

History. — A condition so gross as the presence of gall stones 
could not escape the observation of the earliest observers. It is not 
surprising, therefore, to learn that gall stones were discovered in the 
human body as soon as dissections were made. Folligno at Mantua, 
Tornamira at Montpellier (1586 to 1600 A.D.), are credited as having 
been the first anatomists to have seen gall stones in the human body. 
Fallopius and Vesalius certainly described them, but they seem not 
to have been matters of common recognition by all physicians untiL 
in the course of the seventeenth century, and the pathology of the 
affection was not at all understood until the eighteenth century. 
Morgagni, in his famous work " De Sedibus et Causis Morborum," 
made full description of the condition, but it could not be said that 
any definite knowledge existed concerning it until the chemists 
Fourcroy and Thenard discovered cholesterin, the chief constituent 
of gall stones. In the earlier half of the eighteenth century An- 
dral, Budd, Trousseau, Frerichs, and Murchison illuminated the 
clinical aspects of the subject, and in the year 1851 Fauconneau- 
Dufresne published an exhaustive monograph with reference to 
nearly all the cases published up to that time. 

General Properties. — Gall stones result not from mere thicken- 
ing of the bile, as is commonly believed, rather from precipitation of 
certain substances normally held in solution in the bile. They exist 
for the most part to the number of five to ten in the gall bladder, and 
remain often, in whatever number, entirely quiescent, to produce no 
symptom whatever and to be discovered only upon autopsy. In ex- 
ceptional cases the number is very great — the greater the number 
the smaller the size. Frerichs counted once 1,950, Morgagni 3,000, 
Otto 7,802, in one gall bladder. However numerous, they are nearly 
always of the same construction and vary but little in size and com- 
position in the same gall bladder. They differ in less than four and 
one-half per cent of cases. The largest is that reported by Meckel, 
six by two and one-half inches. Stones vary in size from a grain of 
sand to a pea, hazelnut, walnut, or a cast of a dilated gall bladder. 
One such reported by Fiedler measured twelve centimetres and 



CHOLELITHIASIS. 



447 



weighed forty-six grammes (one and one-half ounces). There is 
not so much variety in shape. Gall stones are for the most part 
polyhedral, with numerous facets and rounded edges. Gall stones 
of very different shape and thickness are much more rarely found 
in the liver itself. They appear here as granular masses, but not in- 
frequently assume the shape of the elongated ducts in which they 
are found, to look like black and shining slate pencils; or present the 
appearance at times, more frequently in the lower animals, much 




Fig. 190.— Two large gall stones from the gall bladder articulated by smooth surfaces (Frerichs). 

more rarely in man, of branching coral. Gall stones formed in the 
liver easily escape from the tubes, which gradually increase in size 
toward the hepatic ducts. Tubular concretions with canals like 
straws were discovered in a case reported by Briquet, following the 
ramifications of the bile ducts to their finest branches. Gall stones 
show also great variety in color, from grayish- white to nearly black.. 




Fig. 191.— Faceted gall stones, natural size (Ziegler). 

The prevailing tint is some shade of brown, the color of the bile pig- 
ment. For the most part they feel greasy to the touch, being smooth 
upon their faceted surfaces ; they may, however, be rough like a 
mulberry or show various erosions like a carious tooth. They may 
often be crushed between the fingers and nearly always nicked with 
the nails. Containing much lime, they may be as hard as stones. 
The weight of a gall stone depends largely upon its freshness. Old 
stones from which the fluid is evaporated float upon water. Fresir 



448 



CHOLELITHIASIS. 



stones exceed in weight the specific gravity of the bile, so that they 
seldom float upon its surface. A gall stone is usually constructed 
of a nucleus, body, and crust or rind. The nucleus may be formed 
of coloring matter with lime, or of a foreign body — a fruit stone, a 
round worm or other parasite, a needle, globule of mercury after 
administration of this drug. Nuclei of foreign bodies are very rare. 
The nucleus is usually mucus, upon and in which cholesterin is de- 
posited. Curiosities are reported where the nucleus has been doubled 
or tripled. The body of the stone is made up chiefly of cholesterin 
with coloring matter. It is usually homogeneous or amorphous, with 
a fracture like soap, and has the consistence of soap. The crust 
is, as stated, usually smooth. It is sometimes studded with warty 
projections. It, too, is made up of cholesterin in smooth layers de- 
posited horizontally at an angle thus to the body of the stone. Some- 
times it contains lime salts. 

Gall stones are formed nearly entirely, seventy to eighty per 





: J>-> 



Fig. 192. 



Fig. 193. 



Fig. 192.— Section of compound gall stone with concentric laminae and with nucleus formed by 
-a smaller gall stone (Frerichs). 

Fjg. 193.— Section of gall stone with concentric nucleus ; concentric laminae only at one end 
(Frerichs). 

cent, of cholesterin. Normally the bile contains but little choles- 
terin, 0.015 to 0.025 per cent. This substance is very slightly solu- 
ble, and is held in solution by the alkaline salts of the bile. Color- 
ing matters, bile acids, fatty acids, and lime salts form, as stated, 
the chief additional constituents of gall stones. Stones composed 
wholly of cholesterin are rare. They vary in size from a pea to a 
cherry, are colorless or show a grass -green hue. The surface is 
usually smooth and the fracture glistening ; they are very light. 
Pure pigment stones are rare. They are generally small and very 
numerous, often mulberry-shaped, with shining fracture, and homo- 
geneous like tar. They sometimes contain copper. Exclusive lime 
stones are very rare. They are nearly always single, whitish-gray 
in color, very heavy, and very hard, rough, and warty upon the 
surface. 

Etiology. — Especial interest attaches to the formation of gall 



CHOLELITHIASIS. 4-49 

stones. What causes the precipitation of the cholesterin ? Upon 
this subject there are various views. 1. Cholesterin accumulates in 
abnormal quantity. What lends support to this view is the fact that 
cholesterin is a product of retrograde change, a process which in- 
creases with advancing age, and gall stones are found more abun- 
dantly after the middle period of life. 2. The natural solvents of 
cholesterin are diminished. Thenard finds the deposit due to dimi- 
nution of the soda salts. Bramson ascribes it to an excess of lime, 
which substitutes soda and thus diminishes the solvent power of the 
cholate of soda. They support this argument with the statement 
that the coloring matter of the bile constitutes the nucleus of so 
many stones. 3. The alkalinity of the bile is diminished by catarrh 
of the gall bladder. The bile has a tendency to become acid under 










Fig. 194.— Section o£ cholesterin stone after removal of cholesterin. 

meat diet, and gall stones are found with greater frequency in high 
livers and in the upper classes of society. Support is lent to this 
view also by the fact that catarrh of the gall bladder is so fre- 
quently found in connection with gall stones. The catarrh may, how- 
ever, be a result as well as a cause. Ebstein declares that gall stones 
contain a skeleton work of mucus, in the interstices of which choles- 
terin plates come to be deposited. This view of the genesis of gall 
stones, as the result of precipitation of the cholesterin from catarrh 
of the bladder, has at the present time the best support. 

The irregular appearance of gall stones, the faceted surface, is 
not due to attrition, as is commonly believed, but to the special 
relations of numerous stones crowded together in the same cavity. 
Cholesterin deposits itself in the interstices between the originally 
more or less globular casts, so that the angular or polyhedral form 
29 



450 CHOLELITHIASIS. 

necessarily results, It is undeniable that gall stones undergo ero- 
sion and disintegration in the gall bladder. Sometimes they split 
with radiating fractures, and these are processes in pathology which 
art attempts in vafn to imitate. Gall stones eroded in this way pre- 
sent the appearance of carious teeth, and the destruction is believed 
to be brought about in the same way, by the action of micro-organ- 
isms. It is not believed by any chemist that any solvent may be 
brought to bear upon gall stones in the body. 

Gall stones have been discovered at every age, but are found in 
greatest abundance toward, at, and after the period of maturity. 
Of three hundred and ninety-five cases collected by Hein, but fifteen 
were under twenty-five and but three of these under twenty — to wit, 
.sixteen, seventeen, and eighteen. There is universal testimony to 
the effect that gall stones prevail among women, and the propor- 
tion of prevalence in the sexes is usually put as 3:2. Fiirbringer 
put it as 4 : 1, Bollinger as 5:2. This disproportion is usually as- 
cribed to the sedentary life, and more particularly to constriction of 
the region of the liver in the mode of dress. In one hundred and 
eleven cases thirty-seven had constricted liver (Bollinger). It is well 
known that whatever interferes with the outflow of bile, whatever 
condition leads to stasis or stagnation, favors the precipitation of in- 
soluble or slightly soluble substances. Hence gall stones are more 
frequently observed in sedentary lives and in the upper classes. Gall 
stones are rarities in hospital practice. Benneke has called attention 
to the frequency with which gall stones are found in connection with 
atheromatous change and excessive development of fat. What re- 
lation these conditions may have toward each other is unknown. 
They are probably coincidents of age, retardations of the activities. 
Glisten noticed that cows suffered with gall stones during the winter 
when confined and fed on hay, and passed them in the summer when 
let out to pasture on grass. 

In the majority of cases gall stones remain entirely quiescent 
during the whole of life. Fortuitous circumstances may, however, 
at any time dislodge them and force them into the gall ducts. Here 
they meet with obstacles at once, as but the smallest stones, one- 
fifth to two-fifths of an inch in diameter, may ever pass through even 
a dilated duct. Fiedler declares that stones only as large as a pea 
can pass. Hyrtl says a stone as big as a finger, Budd as big as an 
almond, may pass. But modern observers maintain that the larger 
stones must either remain in the gall bladder, become wedged in the 
tubes to block them, or be discharged by perforation of the gall 
ducts. Individuals thus pass gall stones through abnormal openings 
between the gall bladder or ducts and the small or large intestine. 
Large stones pass always in this way. Individuals discharge gall 






CHOLELITHIASIS. 451 

stones often without a sign of occlusion. These stones, as stated 
elsewhere, may alone, or especially when cemented en masse with 
fgecal matter, subsequently occlude the intestinal canal. Thus gall 
stones may pass through fistulae into the stomach — a rare diversion ; 
more frequently into the duodenum, more rarely into the colon. As 
curiosities they may meander, to be discharged into any part of the 
ileum, into the bladder and be evacuated with urine, into the pelvis 
of the kidney, through fistulae upon the outside of the abdomen, ac- 
cidentally into the interior of the portal vein, much more frequently 
into the peritoneal cavity of the abdomen, to be followed by the con- 
tents of the gall bladder and to produce death by perforation peri- 
tonitis in the course of a few days. 

Symptoms. — However free from symptoms when quiescent, gall 
stones produce in their discharge a distinct train of signs — first, 
pain. Gall stones may be discharged by unnatural routes, as stated, 
without any or with but little pain. As a rule, however, the pas- 
sage of gall stones along the course of the ducts is attended with 
most excruciating pain. It sets in suddenly, as a rule, and two or 
three hours after a meal. The pain irradiates from the region of the 
gall bladder, especially upward toward the shoulder, sometimes down 
the arm, most frequently toward the angle of the right scapula. 
These pains, as stated, are atrocious in their severity. Women, who 
suffer so frequently from gall stones, declare that the pains of labor 
are not to be compared with the pain of gall stones. As the stone 
comes to rest the pain may cease, to recur with its renewed advance. 
The pain ceases suddenly when the stone either drops back into the 
gall bladder or secures its escape into the duodenum. Jaundice is 
by no means so universally present. It is never present at the start. 
Stones which plug the common duct must necessarily show jaun- 
dice. The persistent cases of jaundice with deep mahogany discol- 
oration, with marasmus, and later with nervous signs, belong much 
more distinctly to carcinoma than to gall stones. In fact, of forty- 
five cases accurately studied by Wolff jaundice existed in but 
twenty, and in but thirty-one of forty-one cases recorded by Fiirbrin- 
ger, so that the diagnosis of gall stones must be made without jaun- 
dice in rather more than half the cases. When jaundice does 
show itself in cholelithiasis, it develops rapidly, so that it may be 
complete and intense in twelve hours after the beginning of the 
attack. The coloring matter of the bile may show itself in the 
urine — sometimes in the absence of recognizable icterus — in less 
than twelve hours (Naunyn). 

Dyspeptic symptoms, eructation, anorexia, nausea and vomit- 
ing, constipation (eighty per cent of cases), belong to the usual his- 
tory of gall stones. As a rule the liver is enlarged. It may be 



452 CHOLELITHIASIS. 

felt below the edge of the ribs. It is sensitive to pressure, and the 
gall bladder may be recognized as a fluctuating tumor or a large, 
pyriform mass. Sometimes, but rarely, gall stones crepitate. 

The diagnosis of gall stone is for the most part easy. The sex, 
more particularly the age, of the individual are most important fac- 
tors. Supreme in symptomatology is gall-stone colic. A history of 
repeated attack often declares the nature of the disease. Jaundice 
may or may not be present ; in the majority of cases the diagnosis, 
as stated, must be made without it. Cholelithiasis may be some- 
times disclosed in the history of intestinal occlusion, or as the cause 
of fatal peritonitis or of complications of various kinds produced by 
meandering stones. The sex, the age, the pain, the jaundice when 
it exists, and with the jaundice the putty-like stools, deep- colored 
urine, itching, insomnia, slow pulse, nervous symptoms when pre- 
sent, make the diagnosis sufficiently easy. The pathognomonic evi- 
dence is the discovery of gall stones in the stools, and the diagnosis 
is indeed sometimes established in this way in the absence of all other 
signs. So the condition has been recognized by accidental discovery, 
or more particularly after a course at a watering place where irriga- 
tion of the blood and inundation of the gall bladder have dislodged 
and discharged smaller stones. In all cases the stools mast be 
passed through a sieve, and every discharge must be examined for 
a week after an attack. 

In differential diagnosis gastralgia must be distinguished and 
excluded. Gastralgia occurs for the most part in younger females, 
or in individuals of either sex affected with other neuroses, migraine,, 
intercostal neuralgia, etc. The pain in gastralgia is more strictly 
epigastric, that of cholelithiasis hypochondriac. The attacks may 
be nearly equally severe and attended with the same precordial dis- 
tress and anxiety. There is, as a rule, a longer interval between the 
attacks of gall-stone colic ; gastralgia is more or less persistent. At- 
tacks of gall-stone colic are aggregated in time in connection with a 
discharge of individual stones. The other symptoms of gall stones 
— jaundice, presence of stones in the fseces, etc. — are of course ab- 
sent in gastralgia. It is questionable if the liver be affected with a 
special neurosis. Budd and Frerichs maintained that the liver suf- 
fered the same neuralgias as the stomach, intestine, or other viscera. 
Hepatalgia, if it exists, would be separated with more difficulty than 
gastralgia, because the pain in neuralgia of the liver would express 
itself in the right hypochondrium. Where the diagnosis rests upon 
this single symptom it must often be held in abeyance. Considera- 
tion of the other symptoms, when present, separates the affections. 

Ulcer of the stomach shows pain more continuous, as a rule 
more circumscribed, and more directly connected with the taking of 



CHOLELITHIASIS. 453 

food. In ulcer there is hyperacidity of the gastric juice. Icterus 
speaks for gall stones. 

Very difficult at times is the distinction between gall stone and 
cancer. Primary cancer of the gall bladder or of the liver in such 
situation as to compress the bile duct is rare. Cancer secondary to 
affection of the stomach is the rule. A previous history of cancer of 
the stomach, more especially the discovery or the recognition of a 
tumor distinctly palpable and separable from an enlarged or dropsi- 
cal gall bladder, is a sign of great importance. Blood in the stools 
may occur in either or neither affection. It is more wont to occur 
in affection of the liver than in gall stone. The discovery of secon- 
dary deposits of cancer rarely assists in the diagnosis. Colic, if pre- 
sent at all, is not so severe in cancer. Aspiration of the gall bladder 
and withdrawal of bile indicate only compression or occlusion with- 
out regard to cause. The author made the first diagnosis by means 
of a needle used as a sound. The long, fine needle of the aspirator 
of Dieulaf oy's apparatus was pushed into the neck of the bladder, 
and the stone was found distinctly palpable to the touch. A surgi- 
cal confrere subsequently exsected a large mass completely blocking* 
the tube. The introduction of a clean needle in this way is unat- 
tended with any particular pain or danger, though objections have 
been urged by inexperienced litterateurs. Age is comparatively 
insensible to pain. The introduction of the exploratory needle causes 
really no more pain at most than a hypodermatic injection. Danger 
has been incurred by the use of soiled sounds. Gall stones are, how- 
ever, sometimes so soft as to escape detection in this way, and carci- 
noma may be so hard as to nearly simulate a gall stone. It must 
not be forgotten that gall stone and carcinoma not infrequently 
coincide in the same subject. Long-continued occlusion with per- 
sistent jaundice, marasmus, etc., in an individual in advanced life, 
speaks stronger for cancer than gall stone. 

Lead colic — saturnism — has a history of exposure, also of re- 
peated attack, without icterus, may show the lead line on the gums, 
or be associated with the arthritis, palsies, wrist-drop, or encephalo- 
pathies of this affection. Kidney stone — nephrolithiasis — is marked 
by pain lower, in the course of the ureters, by alteration in the urine, 
hematuria, etc. 

The prognosis should be made with caution. Gall stones are 
often innocent. They reveal themselves at times only by accident. 
They may, however, at any time give rise to a train of symptoms of 
extreme severity, and they not infrequently cause death. The prog- 
nosis is by no means so grave as it was a quarter of a century ago. 
Surgery scores triumphs in the exsection of gall stones. 

The treatment resolves itself into the treatment of attack and 



454 CHOLELITHIASIS. 

the treatment of the interval— that is, the relief of pain, assistance to 
the discharge, and address to the conditions which lead to the forma- 
tion of the stone. A light attack may be relieved by the external 
application of heat. Flannel garments wrung out of boiling water 
and applied over the whole abdomen and sides, covered in with 
thick, dry cloths, furnish the body the sedative and relaxing influ- 
ence of heat and moisture. This effect may be increased by the in- 
gestion of quantities of hot water. Contact with the seat of disease 
is closer in this way. Where practicable it is advisable to put the 
patient in a hot bath, full length. Resort must be usually had to 
morphia, preferably subcutaneously, gr. J— J, a dose which must be 
repeated as often as necessary. Great caution must be observed 
that the patient be not left inundated with morphia after the sudden 
relief of pain which follows the discharge of the stone into the intes- 
tine or its return to the gall bladder. Patients have been narcotized 
in this way. Pain, when present, neutralizes the effect of opium. 
The virtue of opium may be heightened by the addition of a small 
quantity of atropia, gr. T |o~^ at a dose. The atropia may not be 
repeated as often as morphia. Relaxing effects are better obtained 
by chloral. It is customary to administer with the subcutaneous 
injection of morphia a dose of chloral, g. x.-xx. internally. Chloro- 
form itself, gtt. xv. or xx., may be taken in repeated doses in this 
way. It is not so good as chloral. Even these agents fail in bad 
cases. Resort must then be had to the inhalation of chloroform or 
ether, with the same precaution as is always observed in the admin- 
istration of chloroform for the relief of pain elsewhere. It is here not 
a question of profound anaesthesia, as in the case of the capital opera- 
tions of surgery. The object is to secure rather the relief than the 
abolition of pain or, at least, of consciousness. Chloroform may 
thus have to be given off and on for several hours or for several 
days. The administration of anaesthetics as antispasmodics is good 
practice in the treatment of gall-stone colic. 

The real treatment of the condition is address, as far as possible, 
to its cause. This address is made first by regulation of the diet and 
habits of the individual. Fatty and highly seasoned foods, spices, 
sweets, dry or raw vegetables, cheese, heavy diet, must be eschewed. 
Patients should live largely upon fresh-cooked vegetable food ; meat 
but once a day, lean meat at that. Fluids should be taken in abun- 
dance — soups, milk, especially water ; mineral waters, especially al- 
kaline mineral waters. The virtue of medicated waters is largely 
due to the water itself. It has been shown that alkalies in small 
doses have no effect upon the output of the bile, and in large doses 
hinder it. There is acknowledged virtue, however, in the increased 
alkalescence of the blood and the inundation of the bile ducts with 



ABSCESS OF THE LIVER. 455 

fluid. Gall stones whose very existence has remained unsuspected 
have been discharged during, at, or after a sojourn at a watering 
place, and free libation of alkaline mineral waters remains the best- 
address to the cause. The Carlsbad water enjoys a deserved pre- 
eminence in this regard. Artificial Carlsbad salts, taken in the same 
way as the water — that is, freely, a glassful at a time, with inter- 
vening promenades — have the same effect. Gall stones may be 
dissolved very easily out of the body. They are soluble in ether, 
chloroform, or turpentine. From time to time patent, proprietary, 
and secret remedies have been proposed as solvents for gall stones. 
Durande's was a famous remedy for a time. It consisted of a mix- 
ture of sulphuric ether and turpentine. Whatever virtue it had was 
due wholly to the antispasmodic action of the ether— an action which 
may be much better obtained by the other means mentioned. Ero- 
sion, crumbling, disintegration of gall stones takes place naturally. It 
is supposed to be due to the action of micro-organisms. The discov- 
ery has not yet been made of any agent in chemistry which will bring* 
about the same result. The salicylates undoubtedly make the bile 
flow. The best treatment of gall stones consists in the administra- 
tion of Carlsbad salts in doses of a teaspoonf ul in a glass of hot water 
once, twice, thrice, or more during the day, with the continued ad- 
ministration of the salicylates in divided dosage; regulation of the 
diet of the individual, and change from a sedentary to an active life. 
It is a good thing to keep the gall stones which have been passed. 
Some idea may be had from their number and size, with what esti- 
mate may be made of the size of the gall bladder, as to the presence 
or absence of other stones. 



ABSCESS OF THE LIVER. 

Abscess of the liver ; suppurative hepatitis. — Abscess of the liver 
is a comparatively rare disease. Modern methods of investigation 
have shown, however, that it is more frequent than is commonly 
supposed. The statistics we possess come from the post-mortem 
table, and are consequently fallacious, in that most abscesses as 
well as most other diseases do not come to autopsy. Many unrecog- 
nized cases do not succumb at all. The most accurate records taken 
from the Berlin Pathological Institute disclose abscess in 1.5 per 
cent of autopsies. Abscess of the liver is, therefore, while not a 
frequent, by no means an uncommon disease. In no case is it per- 
haps more true that the life of the individual is more dependent upon 
the recognition of the disease. For abscess of the liver left alone 
usually terminates fatally. 

History. — The lesion of the disease is so gross that it could not 



456 ABSCESS OF THE LIVEK. 

escape the observation of the oldest anatomists. Hippocrates men- 
tioned it and used the actual cautery in opening it. By the time of 
Celsus it had become a matter of dispute whether an abscess should 
be opened by fire or by the knife. The necessity of agglutinative 
inflammation previous to discharge was appreciated by the oldest 
savants. Morgagni, " De Hypochondrorum Tumore et Dolore," 
described the different directions of discharge of a liver abscess. 
Subsequent contributions to the history of the affection concern 
wholly its etiology. The aspirator introduced the new era in practice. 

Etiology. — Abscess of the liver is no infrequent disease of the 
tropics, where it may be said to be indigenous. The statistics men- 
tioned refer to the temperate zone, where the condition is the mani- 
fest result of some embolic or metastatic process. Liver abscesses as 
seen here are always multiple, the single abscess resulting from the 
coalescence of several or numerous smaller depots. The most nu- 
merous abscesses are found in connection with pyaemia, where the 
liver divides the honors with other organs. These abscesses are so 
numerous and so disseminated through the substance of the organ 
as to be unable to unite into one or a few collections. In these cases 
the disease has, as a rule, a rapidly fatal termination. 

Abscess of the liver affects chiefly the period of adolescence and 
maturity. It is rare in infancy and extremely rare in advanced 
age. A curious fact in the history of abscess of the liver is the com- 
parative exemption of the female sex. Females are affected in but 
four or five per cent of the cases. What makes this disproportion 
strange is the fact that dysentery, a disease in which the question of 
sex has no concern, plays such an important role in its production. 
The possible sources of infection of the liver are very numerous. 
Abscess may result as an extension by contiguity of structure : 
thus, in connection with suppurative affections of the gall ducts or 
vasa aberrantia ; often in connection with intrahepatic gall stones ; 
sometimes, much more rarely, from parasites, emigrated intestinal 
worms, distoma, etc. Foreign bodies which have penetrated from 
the stomach may be cited in this connection merely as curiosities. 
The most frequent cause of abscess of the liver in this way is the 
extension by erosion of a gastric ulcer after adhesion to the liver. 
All these cases are, however, extremely rare. As to trauma, it may 
be practically discarded as a cause of abscess of the liver. Frerichs 
reports a case of a laborer crushed between the buffers of railway 
carriages, with evident contusion of the liver and subsequent jaun- 
dice, but without any hepatitis ; and Thierf elder cites a case of a 
soldier shot through the liver, with discharge of bile from the open- 
ing in the right side for a long time, and with complete recovery 
without suppuration. Any ordinary wound suppuration in the 



ABSCESS OF THE LIVER. 457 

course of injury to the liver would riot fall under the head of an 
hepatic abscess. 

The gateway to the liver is the portal vein, and the portal vein is 
the main avenue of metastases in the modern sense — to wit, embolic 
products. The portal vein includes a vast system of tributaries, in 
the domain of any one of which the original disease may lie. Thus, 
in the infant, disease products may come from the umbilical vein, 
in the adult from the gastric, splenic, pancreatic, and more especially 
from the mesenteric veins. Disease of any part of the intestinal tract 
may furnish morbid matter for the liver. The truth is, however, 
that but one disease assumes prominence in this regard, namely, 
dysentery. Abscess of the liver almost never arises in the course of 
typhoid fever, tuberculosis, or disease of the small intestine, but 
arises, as a rule, in the course of that severe or protracted ulceration 
of the large intestine clinically known as dysentery. The associa- 
tion was observed in the earliest times. Annesley thought that ab- 
scess of the liver caused the dysentery, that the abscess altered the 
bile in such a way as to make it irritate and inflame the intestine. 
Budd (1842) first announced the true relations of the diseases, show- 
ing that products were conveyed from the ulcers in the intestine to 
the substance of the liver. In two hundred and one cases of abscess 
of the liver tabulated by Waring, dysentery was found to have ex- 
isted in three-fourths of the cases. The association is so frequent in 
the East that the pathologists there attribute both to the same cause. 
The relation first established by Budd is probably correct. Dysen- 
tery is by no means the exclusive, but is the most frequent, cause of 
abscess of the liver. Other diseases of the large intestine, typhlitis, 
proctitis, haemorrhoids, fistula?, or operations for the relief of these 
conditions, have been followed by abscess. 

The pus-producing micro-organisms act as the direct causes of 
these abscesses of the liver. In certain cases the amoeba? found in 
dysentery (vide Frontispiece, Fig 17) have been discovered in the 
pus of hepatic abscess, but whether as cause or mere coincidence is 
not yet known, as the exact role of these organisms in dysentery 
itself is not yet determined. The amoeba? may be shown in fresh 
faeces, but are best seen in mucus, pus, and blood. The} r are some- 
times seen in the faeces in health. 

Disease products may be conveyed to the liver also by the hepatic 
artery. Cohen found abscess in the liver after the injection of crude 
pus into the thoracic aorta. Putrid bronchitis, ulcerative endocar- 
ditis, suppurative processes about an aneurism, have been attended 
or followed by abscesses of the liver, presumed to have been con- 
veyed through the hepatic artery. The older surgeons— Desault, 
Bichat — spoke of the frequency with which suppurative processes in 






458 ABSCESS OF THE LIVER. 



bone, more especially in the skull, were followed by hepatic ab- 
scess ; and suppurative processes anywhere in the course of the 
systemic veins have been considered satisfactory explanation for 
abscess of the liver. It is well known of the veins of bone that they 
remain patulous under all circumstances and are unable to collapse 
upon their contents ; hence the avenue of transit is kept open. 
More recent investigations, however, have shown that abscess of 
the liver is not more wont to supervene from infection of bone than 
from infection of soft parts. In all these cases the conveyance of 
infectious matter to the liver would have to take place through the 
lungs, whose capillaries are excessively fine. To explain away this 
obstacle it has been assumed that secondary emboli are given off 
from the thrombotic occlusions in the lungs. Unfortunately the 
metastatic products are found in the liver and not in the lungs, and 
metastatic abscess of the liver is much more frequent than the same 
process in the lungs. It is not necessary to appeal to speculation. 
Bacteria may pass through derivative vessels without the interven- 
tion of capillaries. Streptococci may pass a primary to lodge in a 
secondary set of vessels, especially in case of more sluggish circu- 
lation. 

The last source of infection is by way of the hepatic vein, which y 
according to Meckel, is not very infrequent. The older physiologists 
— Magendie, Gaspard — found that mercury introduced into the jug- 
ular vein could be discovered in the liver. Cohen was not willing to 
accept this analogy for emboli. Heller experimented with particles 
of flour enveloped in Canada balsam and found the same results. He 
caused these light particles, against which the objection of weight 
could not be urged, to be sucked into the liver simply by the move- 
ments of artificial respiration, so that the theory of "refluent em- 
bolus " found support in direct experimentation. Heller also reported 
a case where a minute hepatic vein contained cancerous emboli 
which evidently originated f rom affected mediastinal glands. 

Symptoms. — The symptomatology of abscess of the liver is rather 
indefinite. Reliable signs are very few. In certain cases the disease 
is latent and is revealed only upon autopsy, sometimes without the 
existence in life of any symptom of disease, of tener with symptoms, 
vague and indefinite, that have been referred to the stomach or have 
been diagnosticated under the elastic term dyspepsia or the very 
popular term biliousness. 

Usually the liver is swollen. Abscess is most commonly found 
in the right lobe and toward the convexity, so that the enlargement 
in size is upward rather than downward. Dulness begins at the 
level of the fourth or fifth rather than at that of the seventh or 
eighth rib. Sometimes the enlargement is downward, sometimes the 



ABSCESS OF THE LIVER. 459 

weight of the liver causes a descent en masse. Occasionally the tu- 
mefaction may be felt, more rarely it extends to the level of the um- 
bilicus or even to the crest of the ilium. There is often tenderness 
to pressure. Sometimes the liver bulges in the right hypochon- 
drium, obliterating the intercostal spaces. The infection may red- 
den the surface, or the abscess actually point between or under the 
ribs or at the epigastrium, A surface oedema sometimes indicates 
the best site for exploratory puncture. There is pain, as a rule ; a 
dull, heavy sense of weight, as of a stick of wood, across the trunk 
— sensation de barre. More acute pain arises from perihepatitis. 
Pain at the point of the shoulder is often more significant. Shoul- 
der-tip pain — i.e., at the point of the shoulder — or pain in the blade 
or at the angle of the scapula, is, when present, a striking sign. It 
is more marked when the abscess occupies the convexity of the liver, 
and is absent, as a rule, when the seat is elsewhere. Luschka inter- 
preted it first as due to the inosculation of the phrenic, whose fila- 
ments supply the suspensory ligament and convex surface of the 
liver, with the fourth cervical, whose filaments supply the shoulder. 
Twining called attention to the rigidity of the right rectus as 
indicative of abscess of the liver. The sign has some value, and 
is best estimated by comparative test — that is, by alternate palpa- 
tion, with both hands, of the right and left rectus. The truth is, 
the rectus is rigid in any subjacent disease. The rigidity is an in- 
creased physiological tonicity and reflex irritation in protection of 
subjacent parts. 

All or some of the signs of dyspepsia are found in connection 
with abscess of the liver. The tongue is heavily coated. There 
is anorexia, vomiting, nausea, constipation, and the general 
distress associated with these conditions. Depression of spirits 
assumes prominence in abscess of the liver. The terms melan- 
cholia and hypochondriasis indicate the connection which the 
older writers made between disease of the liver and depression of 
spirits. Hammond reported cases in which he was led to explore 
the liver several times, with successful results, on account of these 
symptoms alone. The mental state could have reference to disease 
of this kind only when it could not be accounted for in other and 
more obvious ways. Jaundice occurs as an exception, or, it might 
be said, as an accident, in the history of hepatitis suppurativa. An 
abscess might be so situated as, by its weight, to block the common 
duct. The disease may produce a cachexia along with marasmus, 
but not jaundice, which is found in but sixteen per cent of cases. 
Fever does not belong to abscess of the liver. Chills and fever 
with sweats, sometimes so periodic as to closely simulate malaria, 
indicate pyaemia. 



460 ABSCESS OF THE LIVER. 

The diagnosis rests upon the age and sex of the individual, par- 
ticularly upon the history of previous disease — dysentery, etc. The 
disease may exist without reference to any of these conditions. The 
diagnosis then depends upon the tumefaction, the tenderness, protru- 
sion of chest wall, and possible fluctuation ; the pain, especially the 
shoulder-tip pain ; the fever, the dyspeptic symptoms and depression of 
spirits. The diagnosis rests absolutely upon the discovery of pus by 
aspiration. Aspiration is practised in any doubtful case, with the 
needle of the aspirator, however, rather than that of the hypoder- 
matic syringe, because the abscess is often deep and the pus is 
always thick. The point of election, unless indicated elsewhere, is 
somewhere in the neighborhood of the axillary line, behind rather 
than in front of the line, and above rather than below that diameter 
which might be called the equator of the chest. Where the first 
effort is a failure aspiration may be repeated at different points. 
The author failed once to find an abscess after penetration three 
times before a class of students and once later. On one occasion 
further penetration of the needle was stopped by a hard body. The 
patient subsequently died of peritonitis from perforation of an ab- 
scess, and upon post-mortem examination it was found that one in- 
sertion had penetrated to within one-twelfth of an inch of the abscess, 
where the needle was stopped by a dense pyogenic membrane. The 
puncture is usually painless. In the experience of the writer it 
became necessary upon one occasion to use morphia subcutaneously 
to relieve excruciating, lancinating pain, probably caused by injury to 
an intercostal nerve. 

The abscess may discharge itself favorably. Most frequently it' 
empties into the right lung after agglutinative inflammation with 
the diaphragm and pleura, and discharges itself through the bron- 
chus, whereupon after the lapse of time the abscess refills to repeat its 
discharge. These are the so-called cases of phthisis hepatica. They 
are separated from tuberculosis by the paroxysmal discharge of 
large quantities of pus after intervals of quiescence, by the 
dulness tamquam femoris of the whole posterior portion of the lungs, 
as well as by the absence of the tubercle bacillus. 

Of one hundred and seventy cases tabulated by Thierfelder 
seventy-four emptied into the bronchi, twelve into the intestine, 
twenty-six into the right pleura, twenty-three into the abdominal 
cavity, thirteen into the stomach, four into the pericardium, and one 
into the pelvis of the kidney. No consideration was made of open- 
ings upon the surface, as it was impossible to separate the cases of 
natural and artificial discharge. 

The prognosis of hepatic abscess has entirely changed since the 
day of the discovery of aspiration. The disease had formerly the 



ABSCESS OF THE LIVER. 461 

appalling mortality of eighty per cent, due chiefly to perforation, 
pyaemia, and marasmus. Abscess of the liver has a constant ten- 
dency to rupture. It has no tendency to heal. Scars have been 
found in the liver as curiosities. Neither absorption nor favorable 
discharge can be counted upon. The sword of Damocles is sus- 
pended over the head of a patient affected with abscess of the liver. 
But recovery is absolute after evacuation of the abscess, even though 
there be left but a shell of liver tissue. The liver reproduces itself 
both by hypertrophy and hyperplasia. In rabbits, dogs, and cats 
a loss of three -fourths of the liver is completely restored in thirty- 
six days (Ponfick). 

Treatment. — Drugs are of no value in the treatment of abscess 
of the liver. Indian and English physicians recommend ipecac as 
having the same virtue here as in dysentery. It is difficult to under- 
stand how this may be. Pain may require relief by heat and by 
morphia. The true treatment is the withdrawal of the pus and dis- 
charge of the abscess by aspiration or incision. Sometimes, rather 
exceptionally, a single aspiration suffices, or the operation may be 
repeated once or twice. It is safer not to wait too long, but to cut 
down at once upon the surface of the liver, unite it by suture to the 
abdominal wall, and plunge a knife — or better, to prevent bleeding, 
the blade of the thermo- cautery — into the abscess. In this way a vast 
internal abscess with its manifold dangers is converted virtually into 
an external ulcer whose surface may be subjected to actual inspec- 
tion. The contents of the abscess are usually washed out and the 
cavity subjected to subsequent irrigation with drainage. A few 
weeks suffice, as a rule, to bring the case to a happy termination. 
Progress in the method of operating is shown by comparison of sta- 
tistics. Curtis (1782) reports of the first operations a recovery of 
two of ten cases; De Castro, thirty-four of sixty- one; McConnel, 
twenty-two of thirty-four. In one case in the experience of the 
author pus reaccumulated after a second aspiration. Joseph Ran- 
sohoff, a surgical colleague, practised hepatotomy. The process of 
recovery at the end of the second week was interrupted by a return 
of fever, anorexia, general distress, when it was found that certain 
masses in the anfractious walls had become necrotic and remained 
attached. Under illumination with headlights and laryngoscopic 
mirror these masses were separated with forceps and the bleeding 
bases cauterized. This patient, a woman, finally made a perfect re- 
covery. In the case of excessive pain after puncture, referred to, the 
first incision, which was superficial, discharged about one-half an 
ounce of pus; the patient was extremely emaciated and had suffered 
pain for six months. It was not believed that this quantity could 
account for his condition. A hypodermatic needle, plunged for two 



462 CIRRHOSIS OF THE LIVER. 

inches below the bottom of this abscess, discovered an additional 
depot, from which was discharged over a pint of reddish hepatic pus. 
This patient also made a final recovery. It is safe to say that eighty 
per cent of cases are rescued by timely operation. 

CIRRHOSIS OF THE LIVER. 

Cirrhosis of the liver (xippoS, tawny, orange-yellow); hobnail 
liver, contracted liver, gin-drinker's liver; interstitial hepatitis. — A 
disease of the liver chiefly caused by alcohol ; marked by inter- 
stitial hyperplasia with subsequent contraction of the liver ; charac- 
terized by dyspepsia, ascites, and marasmus. 

History. — The oldest anatomists had their attention attracted to 
the small size and hardness of the liver in certain states of disease. 
Aretseus spoke of the hepar durum, and hepar scirrhus was another 
appellation to indicate hepatic induration. Bianchi even spoke of 
the " jecus in minimam molem retractum," and Yesalius of a case, 
attended with the well-known symptoms in life, where the liver on 
autopsy was found " totum candidum et multis trabeculis asperum," 
etc. Morgagni reported from his own observation, and from that of 
others, undoubted cases of cirrhosis in which the liver was found 
after death "totum granulosum." 

This was, however, the sum and substance of knowledge of cir- 
rhosis up to the time of Laennec (1819). The disease was not yet 
known as an affection distinct from others — from cancer, for in- 
stance — and nothing was known at all as yet either of amyloid or 
syphilitic change, or of the change produced by organic disease of 
the heart. So all these affections were confounded with cirrhosis. 
Laennec came upon the disease quite accidentally in the course of 
his examination of disease of the lungs. He had under observation 
a fatal case of pleurisy with haemorrhage from the lungs, and he 
noticed at the autopsy the curious condition of the liver, which he 
describes in a few words. j As this was the first recognition of the 
disease as a separate affection, the description is worthy of mention. 
He found the liver, he says, "reduced to one-third of its volume, 
concealed in the place it occupies, and seemingly composed of a mul- 
titude of grains of millet seed, of a yellow or yellowish-red color." 
In a footnote he adds: "This is a species of production which has 
been called scirrhus. I will designate it cirrhosis because of its color 
(itippoZ, tawny or orange color). Its development in the liver is one 
of the most common causes of ascites. The liver is always atrophied 
when it contains these cirrhoses." Laennec, therefore, regarded the 
' ' cirrhoses " as new formations, and in accord with this view Aber- 
crombie described the yellow matter of cirrhosis as "in small nodules, 
like peas, dispersed through the substance of the liver." Abercrom- 



CIRRHOSIS OF THE LIVER. 



463 



bie says that the " French writers have a controversy whether the 
cirrhosis or yellow degeneration of the liver be a new formation, or a 
hypertrophia of the yellow substance which they suppose to constitute 
a part of the structure of the liver in its healthy state. No good can 
arise from such discussions/' he adds naively, " as it is impossible to de- 
cide them." In the same year of the recognition of this the common 
form of cirrhosis (Laennec's cirrhosis the French still call it) Bouil- 
laud showed that the nodular or granular appearance was due to 
atrophy of the red substance of the liver, whence resulted a more 
salient projection of the yellow substance. Kiernan (1836) first 
clearly pointed out the hyperplasia of the interstitial connective 
tissue which we now know to be the lesion of cirrhosis, and Gubler 
(1853) first called attention to the fact that the first stage of the dis- 
ease may be characterized by hypertrophy, the second by atrophy of 



c - 



^:^x- 




Fig. 195.— Cirrhosis hepatis (hobnail liver). 



the liver. Finally, Klebs (1868) first proclaimed phlebitis and peri- 
phlebitis of the radicles of the portal vein as the initial anatomical 
factor in the pathology of the disease. It is not the granules, there- 
fore, which constitute the disease. The granules represent constric- 
tions of the liver substance. The constricting agents, the connective 
tissue, constitute the disease, which is properly designated, as Bam- 
berger has shown, " chronic interstitial hepatitis." 

Etiology. — Almost from the very first recognition of the disease 
the cause of it was known. By all writers and clinicians cirrhosis is 
looked upon as an expression of chronic alcoholism. * i Gin-drinker's " 
liver is its common name in England, and the extent of the use of 
alcohol determines the geography of the disease. Males are its most 
frequent victims, because, as Hyrtl remarks, " drinking is one of the 
male accomplishments." But typical cases are encountered among 
females under the same conditions. Even the apparent exceptions 



464 CIRRHOSIS OF THE LIVER. 

support the rule (Niemeyer). " Thus Wunderlich found typical 
cases of the disease in two sisters aged eleven and twelve years; and 
on careful inquiry it was learned that both of them were great 
schnapps drinkers." 

The liver has singular affinity for alcohol in any form. Percy 
found that he could recover alcohol in the bodies of dogs poisoned 
with it, from the blood, the brain, and other organs, but in greatest 
quantity from the liver. The researches of Perrin, Lallemand, and 
Duroy have shown that if we represent by 1 the quantity of alcohol 
found in the blood after the ingestion of a certain amount of it, that 
found in the brain will be represented by 1.34 and that in the liver 
by 1.38. This accumulation of alcohol in the liver, taken in connec- 
tion with the sluggishness of the circulation of the liver, the hepatic 
radicles being the second set of capillaries, furnishes sufficient explana- 
tion of the selection of the liver as the organ which shall suffer most 
from the toxic effects of alcohol. Inasmuch, however, as all drinkers 
do not suffer alike, we must invoke, in addition to the alcoholism, 
some special susceptibility which renders the individual liable to 
cirrhosis. In this respect cirrhosis does not differ from nearly all 
affections. The continuous reception and escape of alcohol in the 
organs of secretion finally induce in them at first irritative and then 
inflammatory change. 

First in order is chronic catarrh of the digestive tract, then de- 
generation of the glandular organs, atheroma of the vesse]s, pachy- 
meningitis, forms of Bright's disease, and, among the later pheno- 
mena, cirrhosis of the liver. Thus epithelial cells and lining cells of 
vessels perish under long-continued irritation of alcohol, but the con- 
nective tissues before they perish are stimulated, under irritation, to 
excessive growth. Alcohol reaches the liver through the radicles 
of the portal vein. These radicles at their ultimate termination are 
among the finest and thinnest, as well as among the richest, systems of 
vessels in the body. The unoxidized alcohol — that is, that which is in 
excess of consumption — passes by easy osmosis through their delicate 
walls and bathes the equally delicate fibres and threads of connec- 
tive tissue which form the soft skeleton work of the recesses of the 
liver. The nuclei multiply, the threads become cords and bands. 
When the connective tissue has attained its full maturity it begins 
to shrink. The liver is so shrunken by the retractile threads of con- 
nective tissue as to look, both upon its free surface and upon the sur- 
face of section everywhere, like the bottom of an ironfounder's shoe. 
"Hobnail liver" it is sometimes called, and the hobs or nodules 
may be sometimes felt in thin people or after tapping beneath the 
skin of the abdomen. It is not infrequent to find the whole of the 
left lobe shrivelled to a mere appendage to the right. 



CIRRHOSIS OF THE LIVER. 465 

Alcohol does not, however, account for all the cases of cirrhosis. 
The connection between alcoholism and cirrhosis is so close as to jus- 
tify incredulity concerning any other cause, and alcoholism must be 
eliminated before the idea of any other cause can be entertained. 
Virchow declared that interstitial inflammation may arise in the 
course of syphilis, and Frerichs cited a number of cases followed hy 
cirrhosis. The syphilitic hepatitis distinguishes itself, as a rule, by 
its irregular development. The process is not so uniformly diffused 
through the substance of the liver as in a true cirrhosis. It is more 
apt to be accompanied by opacities of the surface and gummatous 
masses, and is found in association with evidence of the disease else- 
where. Much interest attaches to the question if intermittent fever. 
malaria, may be considered a cause of the disease. Cantani, of Na- 
ples, ascribes to malaria a potent influence in its production. The 
habits of life at this seaport town by no means exclude the possibility 
of the more common cause. Cirrhosis does not especially prevail in 
malarial climates. The disease should be more common in Africa, 
South America, and in the more intensely malarious regions of our 
own country, if due to this cause. There is no testimony to this ef- 
fect. Botkin declared that he found cirrhosis frequently in connec- 
tion with cholera and typhus fever, but this statement also lacks 
support. Gintrac and Ore found that they could produce cirrhosis 
in dogs by closing the hepatic vein ; and Solowieff observed that 
when the vena porta was ligated slowly and gradually the change in 
the circulation excited an interstitial process in the liver that could 
not be distinguished from that of true cirrhosis. 

The conclusions from these experiments leave at least a loophole 
for the evasion of alcohol as a universal cause, in that possibly some 
other irritant may act like alcohol in producing the characteristic 
changes in and about the walls of the finer vessels. 

The symptoms of cirrhosis irradiate from the liver as the central 
point. Most of them are easy of explanation on mere mechanical 
grounds. A few of the last and worst of them call out a knowledge 
of the physiology of the liver. 

It may never be known just when the cirrhotic process begins in 
the liver, for the first symptoms are purely gastric. Gastric ca- 
tarrh with its well-known attendants precedes the more pronounced 
and peculiar phenomena of the disease for months, or even years. 
Gastric distress, nausea and vomiting, especially in the morning, 
heartburn, constipation alternating ivith diarrhoea, compose the 
train of symptoms that march in the front or by the side of cirrhosis 
of the liver, for months and years at times, before the symptoms of 
more complete obstruction arrive. Gradually, however, the hyper- 
plasia of the connective tissue advances, or gradually it tightens up 
30 



466 CIRRHOSIS OF THE LIVER. 

in its contraction upon intervening liver cells and vessels and ducts. 
The skin groivs sallow and dry, the conjunctival are yelloiv from 
the start, emaciation sets in, all from lack of formation, or from 
slight reabsorption of blocked-up bile ; then water is forced out of the 
radicles of the portal vein into the abdominal cavity, ascites de- 
velops, and from the distended vessels blood may escape into the 
stomach or intestine. Collateral circulation may to some extent 
compensate for the occlusion of the portal vein, and thus obviate for 
a time the worst phases of mechanical hindrance. In fact, it is the 
establishment of collateral circulation that chiefly protracts the life 
of the individual affected with the disease. It is a matter of real 
surprise how many avenues of collateral circulation are brought into 
play in atrophy of the liver. There are vessels in the gastro-hepatic 
omentum from the lesser curvature of the stomach, and in the con- 
nective tissue between the folds of the omentum there are twelve to 
fifteen small vessels which pass from the gall bladder ; besides these, 
the vasa vasorum, the vessels which run along the walls of the por- 
tal vein, hepatic arteiw, and bile ducts ; a fourth group descend from 
the diaphragm in the suspensory ligament ; a fifth, the largest of all, 
the vessels which form the visible network on the surface of the ab- 
domen communicating with the epigastric and internal mammary 
veins ; a sixth, the vessels which ramify upon the oesophagus and 
empty into the diaphragmatic veins. Fatal hwmorrhage has been 
reported by Audibert and Fauvel from oesophageal varices formed 
in this way. Thiebaudet reported a case running a latent course up 
to a fatal haemorrhage, the cause of which on autopsy was found to 
have come from oesophageal veins. Litten found a plexus of dilated 
veins at the lower end of the oesophagus seven times. He attributes 
dilatation of these vessels to the overfilling of the azygos into which 
they empty. Gratia declares that the sclerosis extends throughout 
the whole portal system and helps to cause the ascites. Reitmann 
collected twenty-four cases of severe or a fatal haemorrhage into the 
gastro-intestinal canal. One of these cases had been diagnosticated 
"ulcer of the stomach/' a mistake corrected only upon autopsy. 
De-Bove and Courtois-Suffit also report a case considered gastric 
ulcer. The author had a similar experience. A man of middle age 
was suddenly prostrated by haemorrhage of the stomach, upon the 
street, and was brought into the hospital exsanguine and unconscious. 
There was continuous discharge in large quantity of fluid black blood 
from the month. The haemorrhage resisted all means of relief, and 
the patient died within twenty-four hours, without a history, and 
without a diagnosis other than the assumption of a possible gastric 
ulcer. Autopsy disclosed no lesion of the stomach, but a typical 
cirrhosis with the peculiar and exceptional condition of an enlarged 



CIRRHOSIS OF THE LIVER. 467 

left lobe. It was subsequently ascertained that this individual had 
been a heavy drinker and had suffered from repeated attacks of 
haematemesis. Next to ulcer of the stomach, cirrhosis of the 
liver is the most frequent cause of copious vomiting of blood. 
Rollett reported a case in which haemorrhage repeated itself at inter- 
vals of from four to five weeks for a period of two years. 

Rokitansky first called attention to the circle of tortuous and 
distended vessels about the umbilicus, representing the so-called 
" caput Medusae," present in cases of cirrhosis rather as an exception 
than as a rule. After much discussion concerning these vessels the 
appearance is now admitted to be due to the reopened umbilical vein 
(Bamberger, Baumgartner, and Klebs). These various avenues of 
collateral circulation may become enlarged to such a degree as to 
relieve the pressure in the portal vein and thus allow to disappear 
the ascites already formed, or, if preternaturally of large size, to 
prevent its appearance altogether. It is only in this way that we 
may account for the fact that a certain percentage of cases, accord- 
ing to Frerichs one-third of the whole number, shows no ascites at all. 

Digestive disturbance, partly the direct effect of alcohol, partly 
the effect of arrest of the hepatic function ; emaciation, and corre- 
sponding reduction of strength from the same cause; ascites; enlarge- 
ment of the spleen; haemorrhoids, and haemorrhages from mechani- 
cal occlusions ; enlargement and subsequent contraction of the liver 
itself — these are the chief and prominent symptoms of cirrhosis. 

Jaundice is seldom marked. Some slight discoloration of the 
skin belongs to every case, but genuine icterus betokens rather an 
accidental complication (gall stone, compression by a band of hyper- 
plastic tissue, catarrh of the bile ducts, etc.). Icterus is exceptional 
in cirrhosis, for the simple reason that the destruction of the liver 
cells prevents the formation of bile. 

General dropsy or oedema of the' lower extremities does not be- 
long to the symptomatology of cirrhosis. A great accumulation of 
ascites may compress the vena cava, or a profound debility, the gen- 
eral result of the suppression or annihilation of the function of the 
liver, may cause general dropsy ; but these factors are not peculiar 
to cirrhosis. So accumulations of fluid in the abdomen, or the heavy 
weight of the liver, may interfere with the action of the diaphragm 
and thus induce dyspnoea ; but symptoms on the part of the respira - 
tory system do not constitute an integral part of the history of the 
disease. 

The brain is clear in cirrhosis throughout the course of the dis- 
ease, but toward its close, when atrophy of the liver cells has be- 
come more or less complete, there supervene at times grave symp- 
toms on the part of the nervous system — delirium, convulsions, or 



468 CIRRHOSIS OF THE LIVER. 

coma — which indicate the toxic effects of elements that should be 
excreted with the bile. Pain, or even tenderness, is quite exceptional,, 
and is due, when present, to perihepatitis. The shoulder-tip pain, 
which may be present in cirrhosis as well as in every other organic 
disease of the liver, is satisfactorily explained by the anatomical de- 
monstration by Luschka of the anastomosis of the phrenic and fourth 
cervical nerves. 

The urine in cirrhosis furnishes most valuable evidence. It is 
scanty, dark, and turbid, loaded with urates and other products of 
combustion, the result of the widespread havoc in nutrition. A 
clear and limpid urine would speak strongly against the existence of 
the cirrhotic process. It is now well known that the liver is the 
chief organ in the body in the manufacture of urea, but it is not 
necessary to appeal to this fact, when the waste is so universal, to 
account, in cirrhosis, for the accumulation of the urates (undecom- 
posed urea) in the urine. 

Lepine called attention to the glycogenic function of the liver in 
connection with cirrhosis. The liver makes and uses up sugar in 
greater abundance than any other organ in the body. Lepine found 
that sugar appeared in the urine of cirrhotic patients who had been 
fed with it — a result that might have been inferred from the destruc- 
tion of the .liver cells. In cancer this is not the case, because cancer 
is mostly localized in the liver and does not cause such universal 
abolition of function. 

It is impossible to fix the duration of cirrhosis ; first, because it 
can never be known exactly when it commences ; secondly, because 
the Course of the disease may be interrupted fatally (by a hemor- 
rhage, or as the result of pressure of ascites upon the heart and 
lungs, etc.), or conservatively by arrest of the process in the first 
stage or in the beginning of the second. While it is safe to say 
that the prognosis is bad, it is dangerous to proclaim that the pa- 
tient must die soon, or must die at all of the disease. Cases are now 
abundantly on record, and they may be recalled in the experience 
of every clinician, where the disease process has been brought to 
a stand and the patient has survived for years. 

Diagnosis. — The diagnosis of cirrhosis of the liver in the presence 
of ascites, shrinkage, and patent vessels upon the surface of the ab- 
domen, even without the history, is an easy matter. Most impor- 
tance attaches to the ascites, which means always obstruction to the 
portal circulation, as the most frequent cause of this obstruction is 
cirrhosis of the liver. Obstruction in the course of the portal vein 
itself — pyelophlebitis — is much more rare and the resulting ascites 
much more rapid. In the first stage of cirrhosis of the liver, or in 
the hypertrophic form, the organ is distinctly enlarged. It may 



CIRRHOSIS OF THE LIVER. 400 

extend to the level of the umbilicus or even to that of the crest of the 
ilium. Usually, however, the process of enlargement is more lim- 
ited. The edge of the liver may be felt an inch or two below the 
level of the ribs. It is also usually tender to pressure. Sometimes, 
rarely, the nodules may be recognized by touch. Any slight dimi- 
nution in size easily escapes recognition, especially in the presence of 
much abdominal fat. Under all circumstances the liver usually pre- 
serves its upper line of dulness, as it is pushed up or held in place 
by the colon distended with gas. Much value attaches also to the 
condition of the spleen, which is enlarged in three-fourths of cases. 
The spleen is a reservoir into which is dammed back the blood which 
may not escape into the liver. Gastric and intestinal catarrh, con- 
stipation, tympanites, haemorrhoids, and haemorrhages have been 
sufficiently remarked. The haematemesis of cirrhosis is sudden, un- 
preceded by nausea, and unattended with pain — points which help to 
distinguish it from that of gastric ulcer. 

During the stage or form of enlargement the disease must be dif- 
ferentiated from fatty liver, the icterus liver, amyloid liver, the leu- 
kemic liver, and that peculiar hyperplasia which is known as hyper- 
trophic cirrhosis, or elephantiasis of the liver. Fatty live)' is softer 
and amyloid liver is harder than cirrhosis in the first stage. Both 
these degenerations may be usually ruled out by absence of their 
etiological conditions — syphilis, tuberculosis, suppuration of bones 
and joints. The distention due to obstruction of the bile ducts is 
excluded by the absence of any marked jaundice, and leukcemia is 
ruled out by an examination of the blood corpuscles. 

Elephantiasis of the liver — hypertrophic cirrhosis — is attended 
with a pronounced jaundice from the start. In this condition there 
is no stasis of the portal vein and no ascites. Hypertrophic dis- 
tinguishes itself from atrophic cirrhosis by the fact that the connec- 
tive tissue swells, but does not subsequently contract ; hence there 
is no compression of the radicles of the portal vein, no hyperemia 
in the course of the portal tract, no hcemorrhoids. and no ascites. 
On the other hand, jaundice is p>ronounced and is almost univer- 
sally present. Xevertheless the stools are frequently colored with 
bile. The presence of jaundice under these conditions is explained 
by primary inflammation of the gall ducts. There is in this form of 
the disease great tendency to nose-bleed, frequent pulse, and frequent 
cholsemia (Ewald). The liver may be very much enlarged. The 
surface is usually smooth. The spleen is swollen. The absence 
of the history of alcoholism in more than half the cases, the enlarge- 
ment of the liver and spleen, the presence of jaundice with colored 
stools, and the absence of ascites, sufficiently distinguish this affec- 
tion. 



470 CIRRHOSIS OF THE LIVER. 

Fluxionary hyperemias cause no obstacle to the circulation and 
no ascites. The change which takes place in the course of heart 
disease, the venous stasis which constitutes the so-called nutmeg 
liver, is attended with shrinkage in volume, from which true cirrho- 
sis must be distinguished. It is enough here to recall the fact that 
the cardiac cirrhosis, so-called, must show the evidence of ■ cardiac 
disease in the state of the heart itself and the evidence of disturb- 
ance of the circulation. In cardiac cirrhosis, also, anasarca precedes 
the ascites. It will be remembered always that enlargement of the 
liver due to cirrhosis is very rare. 

Syphilis rarely shrinks the liver to the same degree ; it rather 
subdivides it into additional lobes and lobules, not into granules as 
in the course of true cirrhosis. Leube declares that syphilitic hepa- 
titis is attended with more pain. 

Simple atrophy is found in connection with the marasmus of 
wasting disease, more especially of old age. The liver maintains in 
this condition a smooth surface and edge, shows no granulation, no 
form of icterus, and no sign of block in the portal tract. 

The fluid of ascites must be at times distinguished from that of 
an ovarian cyst. A low specific gravity, under 1015, speaks always 
for ascites. 

Pyelophlebitis and pyelothrombosis are distinguished by the 
rapid development of ascites and other evidence of portal obstruc- 
tion, enlargement of the spleen, haematemesis, venous ectasia? on the 
surface of the abdomen. The discovery of a cause for the condition 
— some ulcerative process in the course of the portal vein or its tribu- 
taries, gall stones, etc. — lends further aid. The discharge of a 
murky fluid by aspiration or through the trocar, as evidence of 
chronic peritonitis, speaks in favor of affection of the portal vein. 

The indicatio causalis in the treatment of cirrhosis is total ab- 
stention from alcohol. The time may come when the patient will 
need some support, and when the light Rhine wines, or even a 
little beer, may be allowed ; but any stronger drink must stand 
absolutely under ban. The diet should be light and nutritious, on a 
basis of milk and other animal food. A few drops of Fowler's solu- 
tion after meals will help digestion, absorption, and more especially 
assimilation. 

As for drugs in general, they may meet the symptoms only. 
With any knowledge of the anatomy of the disease, one may not 
hope to cure it. A stomachic tonic, mix vomica gtt. x.-xx. in a 
wineglass of water, or dilute hydrochloric acid gtt. x.-xx., or the 
tincture of the chloride of iron in the same dose, likewise diluted, 
may be written ut aliqvid faciat and as real aids to digestion. 

In haematemesis or enterorrhagia the treatment should be the 



CIRRHOSIS OF THE LIVER. 471 

very opposite of that employed in gastric ulcer; thus, instead of ergo- 
tin to contract vessels, remedies should be used to dilate the arteries 
and diminish the pressure in the veins. On account of its almost 
immediate action in this regard, the amyl nitrite is especially indi- 
cated, More prolonged effects may be secured with nitroglycerin 
or other less powerful nitrites. 

The only remedial agent that merits the name is puncture of the 
abdominal wall and release from the abdominal dropsy. Early and 
frequent puncture is the result of the testimony of those who have 
had most to do with cirrhosis. Murchison, especially, is emphatic in 
its praise. To wait until life is endangered on the part of the heart 
and lungs and kidneys is to let slip the only chance of arresting the 
disease. The release of the dropsy sets all the absorbents free. The 
peritoneum cannot pick up fluids under great pressure. Moreover, 
and this is the main advantage, the relief of the pressure renders 
possible the establishment of the collateral circulation — a process to 
be favored in every way. The removal of the cause of the disease 
by abstention from alcohol, and the removal of its worst effect by 
relief of the dropsy, give the patient the most scientific benefit. 
Purgatives (like the salines, Carlsbad salts), diaphoretics (like jabo- 
randi), diuretics (like digitalis), tonics (like iron), may all meet indi- 
cations at times in the earlier history of the disease : but paracen- 
tesis will substitute all of them when ascites is fully declared. Not 
only are the lungs relieved in this Avay, but, by the removal of pres- 
sure from the portal and renal veins, the secretion of urine is in- 
creased. " I have known haemorrhage from the bowels/' Murchison 
relates, " arrested by paracentesis in cirrhosis ; and it is a common 
observation that patients with much ascites, who, notwithstanding 
the most powerful diuretics, have been passing only a small quan- 
tity of urine containing much albumin, will, after paracentesis, and 
independently of drugs, i^oid large Quantities of urine free from al- 
bumin.'' The same author quotes the experience of Lyons, of Dub- 
lin, in a case which he tapped thirty-six times at intervals of three 
or four weeks, withdrawing fourteen to sixteen quarts on each 
occasion, with the effect of bringing the disease to a stand at the end 
of one year after the last operation. 

Thus it may be hoped to hold the disease in check, so far as the 
mechanical evils are concerned. Unfortunately, oi r er the physio- 
logical evils there is less control. The body must have bile. A suc- 
cessful biliary fistula which carries off all the bile inevitably leads 
to the death of the animal by inanition. Should the interstitial pro- 
cess continue, which it does in the rule, the liver cells are finally 
killed, bile is no longer formed, and death by starvation results. 
This is the mode of death in most cases of cirrhosis, and death in 



472 



HYPERTROPHIC CIRRHOSIS. 



this way is lege artis. But the liver is immense in its size, it has 
superfluous cells in abundance, it has also remarkable regenerative 
powers, and the disease process may be arrested before destruction 
becomes universal. 



HYPERTROPHIC CIRRHOSIS. 

Hypertrophic cirrhosis; biliary cirrhosis.— Diseases of the liver 
are usually divided into those which shrink and those which increase 
the size of the organ. Cirrhosis, simple and acute atrophy, are the 
affections which shrink the liver. More numerous are the diseases 
which cause its enlargement. In this regard must be considered 
simple hypertrophy, hyperemia, cancer, amyloid and fatty degene- 
ration, echinococcus, and syphilis. Hypertrophy of the liver— the 
so-called hypertrophic cirrhosis, or hepatic elephantiasis— is a disease 
of most modern recognition. The practical value of its separation 

depends upon the fact that it has hith- 
erto been regarded as the first stage of 
true cirrhosis. It is very questionable 
if true cirrhosis be ever attended with 
a preliminary stage of enlargement, 
It is probable that the disease begins 
with atrophy. H} T pertrophic cirrhosis 
— the so-called hyperplasia of the liver 
— differs radically from true cirrhosis 
in the fact that, while the disease af- 
fects chiefly the connective tissue, this 
tissue does not shrink as in the true 
cirrhosis, and hence is not followed by 
symptoms of obstruction — hyperemia 
of the stomach and intestine, haemor- 
rhoids, hemorrhage, and ascites. On 
the other hand, enlargement of the 
spleen from the same cause is univer- 
sally present, as is also icterus of high 
degree. Icterus is always present — 
a point of especial difference between this disease and true cirrho- 
sis. Rosenstein, who met with this affection frequently in Hol- 
land, has come to the conclusion that it is a disease sui generis 
and that it never represents the first stage of atrophic cirrhosis. 
Hypertrophic cirrhosis occurs exclusively between the ages of 
twenty and forty, while atrophic cirrhosis occurs after forty. Al- 
coholism, the most frequent cause of atrophic cirrhosis, does not so 
often produce the hypertrophic form. Malaria with enlargement of 
the spleen plays a more distinct role in its production. The absence 




Fig. 196.— Apparent enlargement of 
the iiver, the result of tight lacing 
(Murchison). 



ACUTE ATROPHY OF THE LIVER. 473 

of icterus in atrophic cirrhosis depends upon degeneration of the liver 
cells. In hypertrophic cirrhosis, instead of acholia there is poly- 
oholia to such degree that the gall ducts are not able to carry it off, 
hence the jaundice. The association of icterus with stools colored 
by the excess of bile distinguishes this disease. The enlargement of 
the liver is usually marked, its consistence moderately hard, its bor- 
der lightly rounded, its surface smooth. 

Enlargement must not be mistaken for simple downward, depres- 
sion, as by effusion in the right pleura, subphrenic abscess, tight 
lacing, etc. 

Hypertrophic is related to atrophic cirrhosis as is the large white 
kidney to the contracted kidney. Though the diseases are indepen- 
dent, the same transition forms may be observed. It is highly prob- 
able that the cases of atrophic cirrhosis characterized by enlarge- 
ment in the first stage are really cases of hypertrophic cirrhosis. 
The disease lasts from a month to three years. Death usually 
occurs with the nervous symptoms of cholsemia. 

The treatment is wholly symptomatic and does not differ from 
that of the atrophic form. 

SIMPLE ATROPHY OF THE LIVER. 

Simple atrophy of the liver is not a disease, but is part process of 
the general shrinkage which occurs in age and marasmus. Conse- 
quently, while the dimensions of the liver are markedly reduced in 
every direction, the symptoms of disease of the liver — pain, jaun- 
dice, haemorrhage, ascites, etc. — are entirely lacking. These points 
make simple and easy a separation of this condition from cirrhosis. 

ACUTE ATROPHY OF THE LIVER. 

Acute atrophy constitutes the gravest, but fortunately the rarest. 
of the diseases of the liver. It is, indeed, amongst the rarest of all 
diseases. Many practitioners of large experience have never seen a 
case, and not more than one case is seen in a large hospital in the 
course of three or four years. As indicative of the rarity of the dis- 
ease, even under favoring conditions, it may be said that Spaeth saw 
it but twice in thirty-three thousand cases, and Braun but once in 
twenty-eight thousand cases of childbirth. The majority of cases 
occur from adolescence to maturity, and in females nearly twice as 
often as in males, usually in them in the last half of gravidity. 

Acute atrophy has been observed to follow cirrhosis of the liver, 
sometimes as a sequel to an acute infection (puerperal fever, typhoid 
fever, etc.), and is always seen to occur in the last stages of acute 



474 weil's disease. 

poisoning by phosphorus. These conditions account, however, for 
but exceptional cases of a most exceptional disease. 

The cause of the disease is unknown. It must be something in 
the nature of a virulent chemical poison, the product, probably, of 
some micro-organism, to produce such rapid and profound disinte- 
gration of the substance of the liver. 

Symptoms. — The disease begins with the symptoms of an or- 
dinary g astro-intestinal catarrh, associated from the start with a. 
light degree of jaundice. There is nothing ominous in the onset of 
the disease. It soon reveals itself, however, in its true character, 
sometimes after a lapse of but few days, sometimes a few weeks, with 
a train of unmistakable symptoms, especially on the part of the ner- 
vous system. These symptoms — delirium and convulsions, sopor, 
stupor, coma — belong to the history of icterus gravis, and distin- 
guish themselves in this disease by the suddenness of their occur- 
rence and rapidity of their progress. In connection with them occur 
also haemorrhages free from the various mucosae, or subcutane- 
ous as in the more protracted forms of icterus gravis. In all cases 
the striking feature of the disease is the shrinkage of the liver. Per- 
cussion reveals dulness at times of but one or two inches. Some- 
times, again, hepatic dulness may not be distinguished at all. 
Occurring in pregnancy, it produces miscarriage with subsequent 
metrorrhagia. 

The disease is distinguished, again, by the absence of fever. Some 
elevation of temperature is commonly present in the inception during 
the stage of gastro -intestinal catarrh. After the shrinkage has com- 
menced or may be recognized the temperature is normal, or even 
subnormal, another distinguishing feature. The urine is reduced 
in quantity. It contains, as a rule, quantities of leucin and tyro- 
sin, together with constituents of bile. Ty rosin often discloses itself, 
after the evaporation of the urine, in the form of delicate needles, 
grouped in colorless bundles or globular masses tinged with bile. 
The urea is often diminished to mere traces. Casts are occasionally 
encountered. 

The duration of the disease is very short. Death occurs in the 
course of two or three days, after the supervention of the signs of 
icterus gravis. The prognosis is fatal. 

The treatment' is wholly symptomatic. Lebert is said to have 
cured a case with benzoic acid and musk ; Teissier, another with aco- 
nite. The absence of details in the description of these cases throws 
doubt upon the diagnosis. Yet Wiesirig reports from the literature 
sixteen cases of recovery. 

Weil's Disease. — Under this title is described as sui generis a 
grave, infectious icterus which begins suddenly with chill and high 



FATTY LIVER. 475 

fever, headache, pain in the loins, bones, and joints, soon followed 
by bronchitis, albuminuria, icterus, and tumor of the spleen. Among- 
recent authorities Alfermann admits and Frankel denies it a special 
place in nosology. 

HYPEREMIA. 

The liver certainly changes its size within certain limits, according- 
to its distention with blood or bile. The icterus liver is always large. 
Overfilling of the blood vessels may also precipitately increase the 
size of the liver. In stasis of the li^er icterus may or may not be 
present, in correspondence with the pressure or lack *)f pressure upon 
the gall ducts. So, too, ascites may be present or absent, according- 
to the degree of venous stasis. Swelling of the spleen is almost al- 
ways present. The characteristic feature is the alteration in the size 
of the liver in correspondence with the increased or decreased tone of 
the heart. Hypersemia of the liver indicates fault in the circulation. 
Usually there is some obstruction in the heart. Valvular disease 
of the heart, weakness of the heart muscle, heart failures, obstruc- 
tions in the lungs, lead to insufficiency of the tricuspid valves and 
regurgitation into the liver. The stasis of the sublobular veins, with 
the altered nutrition of the hepatic cells, gives rise to that change of 
color, seen on section, which is characterized as the nutmeg liver. ■ 

Hypersemia of the liver may, therefore, be diagnosticated only in 
the presence of some fault of the circulation, usually in connection 
with disease of the heart or lungs. The " congestion of the liver/* 
so often remarked by the laity, has reference to distention by bile. 
This congestion, or ''torpidity/' as it is also called, is usually an ex- 
pression of gastro-duodenal or biliary catarrh, and is in no sense a 
true congestion or hypersemia. At the same time it must be recog- 
nized that the liver has certain definite antiseptic properties, interfer- 
ence with which leads to accumulation of toxic matter in the intes- 
tine. When a section of liver tissue is 'destroyed' or a large artery tied, 
the animal dies in the first instance in eight to fourteen hours and in 
the second in four to eight hours. But if injected with an emulsion 
of liver substance it may be kept alive for several days (Masini). 
The dulness and distress of " biliousness " may be thus a real expres- 
sion of torpor or inactivity of the liver. 

FATTY LIVER. 

Fatty liver never reaches the excessive grades of enlargement of 
amyloid degeneration. In the most extensive case of fatty degenera- 
tion the liver does not reach below the umbilicus. Its surface is 
perfectly smooth, its consistence remarkably soft. Fatty liver occurs 
more especially in connection with tuberculosis, cancer, phosphorus 



476 CANCER OF THE LIVER. 

poisoning, where it meets its main expression. It is seen also in 
•certain cases of obesity. 

It is, as a rule, unattended with symptoms of disease of the liver — 
pain, jaundice, and ascites — and is of interest only from the point of 
view of differential diagnosis. 

AMYLOID LIVER. 

Amyloid liver is only a part process of a widespread degenera- 
tion. Amyloid degeneration is a peculiar retrograde change in the 
hepatic tissue. It is usually found in connection with amyloid de- 
generation of the kidney, of the spleen, often of the mucous mem- 
brane of the intestinal canal. The recognition of the affection 
•depends, therefore, upon its association with lesion of other organs. 
It is found as the result of chronic suppurative processes, more 
particularly of bone caries and necrosis of bone, especially of pro- 
tracted course, or suppurative processes of the skin, mucous mem- 
branes; sometimes in serous membranes. Empyema may precede 
for months the development of an amyloid change. Syphilis, cancer, 
malaria, leukaemia, Bright's disease, pj^aemia, rheumatism, exhaust- 
ing discharge, may develop this change. 

In amyloid degeneration the liver reaches at times great magni- 
tude. It may largely fill up the abdominal cavity. As a rule it 
reaches to the vicinity of the umbilicus. The surface is perfectly 
smooth, the border round, and the consistence very hard. In 
exceptional cases the enlargement may be but slight and the border 
sometimes remains sharp. There is no icterus and no ascites, save 
that which occurs in the last stages of the disease in connection with 
anasarca. The dropsy is confined to the lower extremities. The 
condition is recognized in the size of the liver in every direction, by 
its uniformly smooth surface, resistance, and by the absence of 
icterus and ascites. 

The etiology of the affection — bone caries, tuberculosis, inveterate 
syphilis, chronic malaria, carcinoma — bespeaks the character of the 
disease. Attention is usually directed to the liver by the discovery 
in the urine of evidence of amyloid degeneration of the kidney. 

CANCER OF THE LIVER. 

Cancer of the liver is usually secondary. It is primary in but 
eighteen per cent of cases (Siegrist). In the vast majority of cases it 
occurs in the course of cancer of the stomach. Sometimes the can- 
cer is quiescent in the stomach, while the secondary deposit in the 
liver assumes prominence and overshadows the primary lesion. 
Cancer of the stomach may be secondary also to cancer of the 
breast, uterus, rectum, or other organ. Thus a digital examination 



CANCER OF THE LIVER. 477' 

of the rectum or vagina has often led to a true interpretation of 
the nature of a chronic or grave affection of the liver. Cancer of 
the liver is sometimes latent, and has been recognized upon the post- 
mortem table in the absence of signs in life. It betrays itself 
usually, however, with unmistakable signs. The volume of the 
liver, as determined by palpation and percussion, is early in- 
creased, and soon reaches enormous dimensions. It may extend 
from the angle of the scapula to the ileum. The surface is hard, 
but not smooth; it is broken by protuberances and nodules. 
Icterus is present in about half the cases, and depends in degree 
upon the site of the deposit. Ascites is present, but is not, as a 




w 

Fig. 197.— Cancer of the liver, a; with multiple metastases, &, 6, b; within the liver (Ziegler\ 

rule, pronounced. The body of the liver may be usually felt 
through it under forcible, especially intermittent, palpation. The 
fluid may be clear, but it is usually turbid or bloody. Pain may be 
present or absent, and, when present, is rather an expression of a 
perihepatitis. The stools vary in color and consistence, according 
to the presence or absence of bile. In the later course of the disease 
they are often stained or tinged with blood. 

As in cancer elsewhere, cachexia gradually develops. The dis- 
ease advances rapidly in the liver, and usually takes life in the 
course of six months to a year. 

Treatment is wholly palliative. 

Echinococcus of the liver is discussed in connection with tape- 
worms. 



DISEASES OE THE 

ORGANS OF RESPIRATION. 



CHAPTER V. 

DISEASES OF THE NOSE AND THROAT. 
DISEASES OF THE NOSE. 

Diseases of the organs of respiration begin with the affections 
of the nose. Acute catarrh of the nose is distinguished as coryza. 
It is often found in association with catarrh of the conjunctiva and 
of the throat, especially in connection with various infections, to the 
effluvia of which these mucous membranes are exposed. These sur- 
faces constitute the avenues of invasion. Or the affection begins in 



. X-P. 






•ts .-km \ 

[ Fig. 198.— Nasal mucus: a, ciliated cells: b. leucocytes; r, capsule cocci; d, bacilli; e. micrococci. 

the nose and extends through the throat to the bronchial tubes. 
More frequently the affection remains confined to the nose, to con- 
stitute an acute or chronic nasal catarrh. 

Acute nasal catarrh is the evident expression of some outside 
irritant. But that the irritant may also come from within is proven 
by the effects of iodine, which, in toxic dose or in susceptible indi- 
viduals, produces exquisite nasal catarrh. The disease announces 
itself by dryness, burning, and irritation, which produces more or 
less constant sneezing. Very soon the surface is moistened with a 



DISEASES OF THE NOSE. 



-±79 



discharge ; watery mucus accumulates and escapes upon the face, 
requiring the constant use of a handkerchief. The mucous mem- 
brane swells, often to occlude the nares. The spongy structure of 
the mucous membrane permits rapid swelling, so that mere gravity, 
as in lying upon one side of the body, will block one side of the nose, 
and the block may be changed by changing posture. Fever, more 
or less headache, hebetude, soreness and pain in the frontal region 
which may be due to extension of inflammation to connecting- 
sinuses, are further signs of an acute nasal catarrh. 

Chronic catarrh of the nose is much more frequent. It results 
at times from repeated attacks of acute catarrh. It occurs most 
frequently in connection with scrofula (tuberculosis) and syphilis, 
where it leads to alteration of structure, hyperplasia and occlusion. 




Fig. 1&9. Fig. 500. 

Fig. 199.— Adenoid tissue at vault of pharynx (Luschka\ 
Fig. 200.— Posterior nares in the rhiaoscope: a. uvula; b, b, orifices of the Eustachian tubes. 



or atrophic change. The process extends also to the posterior nares. 
and is liable to invade the Eustachian tubes; it is therefore a com- 
mon cause of deafness. The secretion is altered: it becomes more 
or less profuse and offensive (ozaBna) ; the true gland structure in 
the mucous membrane is destroyed. According to Schuchardt the 
ciliated epithelium is destroyed, and substituted by squamous cells, 
which much more readily suffer decomposition. Subsequently the 
bone substratum itself may be affected. Thus chronic catarrh is, as 
a rule, a specific process. 

Syphilitic catarrh is especially wont to be attended wittfdestruc- 
tive change, ulcers, and necroses. Gummatous perichondritis breaks 
down the cartilage aad bony structure, with the formation of exces- 



480 DISEASES OF THE NOSE. 

sively offensive discharge, which dries to form crusts, under which 
the destructive change continues, to constitute the syphilitic ozsena. 

Treatment. — Acute catarrh of the nose is a common expression 
of a " bad cold. " It is usually of short duration, and is best relieved 
by quiet and rest in the house. Sometimes an attack may be cut 
short with a dose of Dover's powder gr. viij.-x., and hot baths and 
hot drinks to excite profuse diaphoresis. Of a solution of atropia, gr. 
i.- 3 i , three drops, repeated two or three times a day, will often 
quickly relieve the distress of acute catarrh. See also treatment of 
angina and of acute laryngitis. 

Chronic catarrh of the nose is a malady of months', often years', 
duration. Successful therapy depends upon a recognition of its 
cause. Syphilis calls for the use of mercury, especially by inunc- 
tion, and iodide of potassium, under which the most obstinate and 
destructive changes speedily yield ; scrofula for tuberculin, cod-liver 
oil, creosote, and the iodide of iron. Free ventilation of rooms with 
pure, fresh air is in all cases a sine qua non. Local treatment is of 
great value. The nose must be kept clean with douches of salt water. 
Warm water, containing a drachm each of common salt and carbon- 
ate of soda to the pint, may be snuffed up the nose or introduced by 
means of a syringe, care being taken, by keeping the source low, to 
avoid penetration of the Eustachian tubes. 

Ointments keep the mucous membrane soft and the fossa? open: 

^ Acidi borici gr. xv. 

Unguenti petrolati § ss. 

M. A mass the size of a bean or hazelnut to be snuffed up the nose morning and 
evening. 

Or— 

3 Hydrargyri oxidi flavi gr. v. 

Unguenti petrolati 3 ss. 

M. To be introduced the same way. 

Fetid atrophic processes are best treated with iodoform, creolin, 
creosote, or that combination known as europhen, which is an iodide 
of creosote, hence less noxious in its effects, as well as to the sense 
of smell, than iodoform. The remedy is best introduced in the form 
of an ointment: 

_3 Europhen gr. x. 

Olei olivne 3 i. 

Lanolini. ... 3 iij. 

M. 

Solutions of pyoktanin, 1 : 100, introduced with a saturated cot- 
ton-wrapped sound, purify all secretions and rapidly penetrate the 



DISEASES OF THE LARYNX. 481 

recesses of the nose. A very effective treatment of ozsena consists 
in the application of the creolin-ichthyol solution. The nose is first 
washed out with an alkaline solution and thoroughly cleansed with 
a cotton-wrapped sound. The ichthyol is applied in a five-per-cent 
solution of creolin. The bad odor rapidly disappears. Hypertrophic 
processes and occlusions are best removed by concentrated solutions 
of trichloracetic acid, which is also applied with cotton. The pain 
which occurs a few minutes after the application slowly subsides. 
It is not so easily subdued by previous applications of cocaine as 
with the use of the- galvano-cautery. The mucous membrane is 
burned snow-white under this acid. The process of healing takes 
place without reaction or pain. The incrustation is desquamated 
quicker than after burning (Killian). Finally, the practitioner may 
have recourse to the use of the galvano-cautery. Batteries with 
suitable end apparatus are now furnished at very reasonable price. 

Polypi (mucous) which may undergo cystic degeneration, adeno- 
matous, telangiectatic, or fibroid growths, more exceptionally chon- 
dromata, steomata, sarcomata, occur in the nose or connecting cavi- 
ties. 

Polypi, etc., must be extracted by surgical means. 

DISEASES OF THE LARYNX. 

The progress of medicine is scarcely anywhere better exemplified 
than in the diseases of the larynx. Less than half a century ago the 
interior of the larynx was an undiscovered country. The physician 
was able to recognize laryngeal disease in general, but was in no 
way able to distinguish the character of the disease. The deepest 
recesses of the body were not more dark than the interior of the 
larynx. 

History. — Bozzini (1804) made an attempt to illuminate the inte- 
rior of the body, but, so far as the throat was concerned, the attempt 
reached the pharynx but not the larynx. Cagnard de Latour in 
1825 actually introduced a mirror into the throat, but failed in reach- 
ing any conclusions for want of light. Two years later Babington 
invented a glottiscope with mirror and tongue depressor, and ac- 
tually used reflected light, by means of which he claimed to have 
been able on several occasions to see the epiglottis, but nothing more. 
Selligues (1832), a victim of tuberculosis, made the attempt to in- 
spect his own larynx, in the hope of being able to treat himself. He 
constructed a speculum out of a closed tube, and, as might have been 
imagined, saw nothing. Baumes introduced a mirror fastened to 
the end of a fish bone as a stem, and claimed to have seen by the aid 
of it ulceration in the larynx. Liston and Warden, with the use of 
mirrors and handles, declared that they were able to distinguish 
31 



482 DISEASES OF THE LARYNX. 

oedema and swelling of the epiglottis. Thus far crude experiment 
with barren result. The real illumination was made by a singing 
teacher, the celebrated Manuel Garcia, who introduced a mirror 
deep in the throat, heated it in warm water to prevent the cloud of 
the breath which shut off all sight, and fixed his patient so that the 
sunlight fell directly upon the glass in the throat, and so by the ad- 
justment of the mirror was able to study the interior of the larynx. 
Garcia studied the larynx from the standpoint of the vocalist. He 
watched the play of the vocal cords during phonation and respira- 
tion, and described the process in a monograph entitled " Physio- 
logical Observations on the Human Voice," communicated to the 
Royal Society in 1855. With the use of an outside mirror Garcia 
introduced auto-laryngoscopy. He studied the process in his own 
throat. Strange to say, this remarkable observation excited no inte- 
rest or attention, and it was not until two years later that Turck, an 
assistant at the General Hospital in Vienna, made these observations 

anew. Turck also used sunlight, and 
hence was able to study the subject only 
in propitious weather. He did not re- 
alize the extent of his discovery. It 
was different with Czermak, who bor- 
rowed the mirror of Tiirck and de- 
veloped laryngoscopy. Tiirck had al- 
ready discovered the ease with which 
uJP^ the throat might be inspected by with- 

„ nM ^ T ,7 ,,„ ooVlM drawal of the tongue. Czermak adopt- 

Fig. 201.— Normal larynx and trachea » *- 

to bifurcation of bronchi. ed this method. He was the first also 

to use artificial light, which enabled him 
to study the subject day and night. He became inspired with it. 
He was like a man who first saw the light after a long blindness. 
He travelled about to the different universities of Europe, gave di- 
rections in every direction, and practically established, or gave 
the incentive which resulted in the establishment of laryngological 
clinics everywhere (Fleischer). A few years later Bruns took a 
tumor out of the throat of his own brother ; and in less than a de- 
cade a host of observers — Semeleder, Schrotter, Gerhardt, Ziemssen, 
Voltolini, Tobold, Levin, Fauvel, Mackenzie, B. Frankel— described 
every process of disease. Artificial is now substituted in our day by 
the electric light, which gives natural colors and appearances ; and 
these discoveries, with the invention of much apparatus, including 
the galvano-caustic storage battery with suitable electrodes, have, so 
to speak, turned the larynx inside out and rendered all its diseases, 
if not curable, recognizable and amenable to treatment. 

The diseases of the larynx which most commonly call for treat- 




CATARRHAL LARYNGITIS. 483 

ment are acute and chronic catarrh — i.e., acute and chronic laryn- 
gitis, including laryngismus stridulus (spasmodic croup), true croup, 
oedema, perichondritis, and paralysis. The general diseases which 
affect the larynx are tuberculosis, syphilis, and cancer. They are 
none of them confined to the larynx, with the exception, perhaps, of 
cancer, which is not infrequently primary in the throat. 

Catarrhal Laryngitis is very frequent and is one of the ex- 
pressions of a common cold. Just how catching cold produces laryn- 
gitis is as difficult to explain as is the process elsewhere. It is often 
assumed that hyperemia liberates toxic matters from micro-organ- 
isms at other times latent or quiescent. It is known, for instance, of 
the tubercle bacillus, that it abounds in the lymph spaces and vessels 
of the larynx. These bacilli are derived in all cases through lymph 
tracts from the lungs. They almost never penetrate from the sur- 
face of the mucosae. The subjects of tuberculosis are particularly 
prone to suffer laryngeal affections. The first stage of tuberculosis 
is a stage of catarrh, which differs in no way from catarrh from any 
other cause. There are individuals who suffer laryngitis with every 
exposure. They are for the most part individuals who lead indoor 
lives, in whom the mucous membrane is sensitive by long stay in 
over-heated and ill- ventilated apartments. Criers, public speakers, 
singers, preachers, auctioneers, are particularly prone to laryngitis. 
The laryngoscope reveals the condition. The mucous membrane is 
swollen, reddened, tumefied. The vocal cords, which should glisten 
white like dog's teeth, are tinged with red here and there, or are 
more or less uniformly red. The inside of the throat looks like a 
piece of red flannel. It is seen that the cords may not so closely 
approximate each other in phonation. The slightest swelling, or the 
slightest failure in muscular tonicity, or the slightest accumulation 
of mucus changes the character of the voice. The voice loses its 
individuality ; it becomes altered, hoarse, husky; the individual may 
make himself heard only by straining efforts. Finally the voice is 
lost altogether and the patient is reduced to whispers. 

Acute catarrh distinguishes itself by hyperemia, chronic catarrh 
by hypertrophy. In chronic catarrh the throat is not so red. The 
hue is more dusky, slate-colored in places. The membrane is thick, 
ened. The arytenoid cartilages are hindered in their free move- 
ments. The interarytenoid band is more thick. There is, however, 
no break of the surface, no such hyperplasia of tissue as to consti- 
tute a tumor, and, other than thickening of the mucous membrane, 
no deformity. Motion may be more sluggish, but there is no paraly- 
sis. Often there is a sensation of burning and dryness. There is 
frequent, harassing, rasping cough, with the extrusion of tough, 
glutinous mucus, which may be seen adhering to the vocal cords or 



484 CATARRHAL LARYNGITIS. 

t other parts of the interior of the larynx. There may be in an acute 
inflammation slight fever. In chronic catarrh the symptoms are less 
intense but more persistent. The voice remains husky ; it becomes 
susceptible to changes in the weather. Raw, damp weather aggra- 
vates chronic catarrh ; mild, dry, warm weather benefits it. Indi- 
viduals secure exemption by spending the fall and winter in Florida, 
Lower California, or other warm climate. 

The treatment demands above all things rest, and the difficulty 
of obtaining satisfactory result is due to the fact that the avocation 
of the individual requires more or less constant use of the voice. 
Singers must sing and preachers must preach. Many of the victims 
of chronic catarrh of the larynx have a mania to talk. In some of 
the worst of these cases the long-continued catarrhal process has 
actually brought about usury of the vocal cords. Irrepressible 
talkers affected with this disease have actually talked away parts of 
the vocal cords. 

The general principle of treatment consists in the application of 
astringents. The best astringent is nitrate of silver, one- or two-per- 
cent solution, applied always with the cotton- wrapped sound under 
the laryngoscope. The plan in present use is to saturate quite a 
large mass of cotton in solution and apply it with the laryngeal 
forceps directly into the throat, if necessary after an application of 
a four-per-cent solution of cocaine, which is itself sometimes used 
alone in highly sensitive cases. Practitioners have preferences in 
the choice of astringents. Tannin has advocates, as has also ferric 
alum. Others prefer the more antiseptic preparations — carbolic acid, 
permanganate of potash, sublimate solutions, thymol, pyoktanin, 
aristol, dermatol, etc. In chronic catarrh with much hypertrophic 
change no remedy equals in value the galvano-cautery in light and 
momentary touch. Inhalations are of value, best by steam from 
the atomizer and medication with common salt, preferably with the 
bicarbonate of soda, saturated solution, or an astringent, as specified. 
Gargles assist in controlling an associate pharyngitis. . They are of 
no value in laryngitis proper. Sponges should be abolished, as 
should also brushes. Applications should be made with fresh cotton 
by means of the laryngeal forceps. 

Acute cases are often relieved by compresses, cloths saturated in 
water, hot or cold, applied about the throat and enveloped in thick, 
dry cloths. Broken doses of Dover's powder, or a round dose of 
Dover's powder, ten grains at night, with a hot bath and free dia- 
phoresis, may cut short an acute case. A round dose of quinine with 
an ounce of whiskey may have the same effect. Treatment in gene- 
ral is that of a common cold. Chronic cases are especially defiant of 
treatment. They try the patience of the practitioner. They are 



CEDEIUA OF THE GLOTTIS — PERICHONDRITIS. 485 

often associated with hypochondriasis. They furnish the basis for 
the specialist. They are often entirely relieved, as stated, only by 
change of climate. 

(Edema of the Glottis is a much more serious affection. It 
occurs most frequently as the result of an outside cause, as from 
Bright's disease, disease of the lungs, emphysema, heart disease, etc. 
In only one-third of the cases does oedema arise from affection of the 
larynx proper, and then more frequently in the course of acute 
laryngitis. (Edema gives great gravity to an ordinary case of laryn- 
gitis, and, in association with oedema of the lungs, is often the termi- 
nal link in the chain of disease process. (Edema may extend above 
the larynx to involve the palate, and more especially the uvula, 
which sometimes has the appearance of 
a Malaga grape. The rim of the oede- <Q 

matous epiglottis may occasionally be ' ■" JsjC/T._ 

seen on depressing the tongue. For the |t 

most part the condition must be felt, not .ASfSril "' ■ ; ^r 

seen. It may be recognized, by the fin- . '^ ai =^*^ 
ger introduced deep in the throat, as a \ \^ 4 

soft, semi-fluctuating mass about the r ' 

base of the epiglottis. It is necessary 
to recognize oedema early, that the fluid 

may be evacuated while it will flow. ' J 

Scarification is the treatment, with a bis- : '' 

toury wrapped close to the end that it \^ ^*A^ - W 

may not penetrate too deeply. Where 



Tt is rmressarv i I -~^ >§f ! 



Fig. 202. — OSdema of the glottis 
(Cohen). 



incisions are not practised sufficiently 

early the fluid sets — i.e., gelatinizes — 

and subsequent scarification will not evacuate it. Resort must then 

be had to intubation or tracheotomy. 

Perichondritis depends upon the graver diseases, tuberculosis, 
syphilis, and cancer. It does sometimes occur, however, in the course 
of an excessively obstinate chronic catarrh. In the majority of cases 
it shows itself as a more acute complication in the course of septic dis- 
eases or the infections. Perichondritis may occur in consequence of 
variola, rubeola, more rarely scarlatina, still more rarely erysipelas. 
The cricoid cartilage is chiefly the seat of the disease. The thyroid 
is rarely involved, and the arytenoid only in the most exceptional case, 
It is recognized by the pain in the region of the larynx, more espe- 
cially by the tenderness. Fluctuation, as detected by outside pal- 
pation, may reveal the presence of phlegmonous inflammation or 
abscess. 

The diagnosis is usually disclosed by the laryngoscope, which 
shows at a glance more or less deformity. 



480 



TUBERCULOSIS OF THE LARYNX, 



The prognosis will depend upon the original disease, as well as 
upon the amount of deformity. It is always grave, because of the 
gravity of its cause. Immediate danger of stenosis may be obviated 

by incision, by dilatation, by intuba- 
tion, by tracheotomy. The procedure 
; will be determined in the individual 

case. 

Next to catarrhal laryngitis the 
most frequent affection is Tuber- 
culosis, caused, as stated, by the 
direct invasion of the submucous 
lymph spaces and vessels by the tu- 
bercle bacillus derived from the lungs. 
It produces at first only catarrhal 
changes, present at times and absent 
at times, but with more or less ten- 
dency to continual recurrence, later more pronounced hyperemia, 
more limited localization of lesion, tumefaction, ulceration, eventual 
extreme deformity. Cough, dysphagia, and dyspnoea, along with 




Fig. 
larynx. 



V r r ~ 



-Advanced tuberculosis of the 





Fig. 204. — Papilloma of the larynx (Cngals). 



Fig. 205.— Fibroid tumor of the larynx. 



complete aphonia, distinguish these cases. The aphonia assumes 
prominence. It is sometimes the only symptom to indicate disease of 
the larynx, so far as outside symptoms go. The laryngoscope clears 
the diagnosis at a glance. Very often the in- 
side of the larynx cannot be seen at all, but 
is hidden under an immensely swollen, tume- 
fied, cedematous, sometimes ulcerated epiglot- 
tis. It is interesting to observe the gradual 
elevation of this overhanging epiglottis under 
applications of cocaine, and more especially 
under the use of tuberculin. The same changes 
are observed in the interior of the larynx, on 

the lips of the glottis, viz., tumefied cords, hyperaemic, cedematous, 
distorted bands, obliterated sinuses, various deformities. 

The prognosis is exceedingly grave. Laryngeal tuberculosis usu- 




Cancer of the 



PARALYSIS OF THE LARYNX. 



487 




Fig. 207.— Normal larynx. Position of cords 
in deep inspiration. 




Fig. 208.— Normal larynx. Posi- 
tion of cords in phonation. 




Fig. 209. — Paralysis of the Fig. 210.— Paralysis of both thyro- Fig. 211.— Paralysis of the aryte 
arytenoid in phonation. arytenoids in phonation. noid and both thyro-arytenoids in 

phonation. 





Fig. 212.— Paralysis of left recurrent 
in respiration. 



Fig. 213.— Paralysis of left re- 
current in phonation. 




Fig. 214.— Paralysis of right pos- Fig. 215.— Paralysis of both pos- Fig. 216.— Paralysis of both recur- 
erior crico-arytenoid in respira- terior crico-arytenoids in respira- rents— cadaver. 
iou tion. 



488 SYPHILIS — PARALYSIS — TUMORS OF THE LARYNX. 

ally defies all kinds of treatment. A patient with marked laryngeal 
tuberculosis has without treatment, as a rule, at the outside not more 
than six months to live. 

The treatment is that of tuberculosis in general, especially by tu- 
berculin, creosote, arsenic, cod-liver oil, altitude, etc. Local treat- 
ment consists in the use of cocaine to allay extreme hyperesthesia and 
dysphagia; the insufflation of iodoform; or, far better, the application, 
with a brush, of lactic acid solutions, twenty to eighty per cent. The 
last stages demand morphia by insufflation. Applications do not 
reach the larynx at all unless made under the mirror in a good 
light. 

Curious lesions occur in the mucous membrane in consequence of 
typhoid fever. Ecchymoses, erosions of tissue, show themselves on 
the under surface of the epiglottis, and especially on the front wall 
of the larynx, produced by the typhoid bacillus, or more probably 
by bacteria of mixed infection. 

Syphilis shows itself in the larynx at first as an ordinary catarrh; 
subsequently, with infiltration, hyperplasia, and ulceration, most 
frequently of the epiglottis, vocal cords, and posterior wall of the 
larynx. Extensive necroses may denude large masses of cartilage. 
Syphilis shows itself also in the form of gummatous deposit in the 
epiglottis and vocal cords, which may result in ulceration and de- 
struction, perichondritis and necroses, with great deformity. The 
diagnosis rests upon the recognition of the disease elsewhere in the 
body, and upon the results of specific treatment by mercurial inunc- 
tions, the iodides, which should always be tried in questionable cases, 
that the patient may have the benefit of a doubt. 

Paralysis of the Larynx occurs in connection with lesions of 
the brain and spinal cord (bulbar lesions), as the result of pressure 
upon nerve trunks, as of the left recurrent in aneurism of the aorta, 
and in consequence of accident to or disease of the larynx itself. 
These various paralyses are shown in the figures on page 487, taken 
from Wesener's work, on diagnosis. Aphonia or dysphonia, some- 
times dyspnoea and dysphagia, are the principal signs of these para- 
lyses, which are treated generally by address to the cause, and locally 
by strychnia subcutaneously and electricity. 

Tumors of the larynx, polypi, etc. , which are easily visible under 
the laryngoscope, may be removed, under cocaine ten per cent, with 
the forceps, or may be destroyed by caustics, or, better, by the gal- 
vano-cautery. Cancer, which shows itself in more advanced life 
with pain, lymphadenitis, and deformity, justifies extensive exsection, 
with, if necessary, substitution by an artificial larynx. 



OHAPTEE VI. 

DISEASES OF THE LUNGS. 
BRONCHITIS. 

Inflammation, for the most part infection, of the bronchial 
tubes. 

Bronchitis is the most frequent of all diseases. It constitutes 
three-tenths of all internal maladies. It affects all ages, with es- 
pecial predilection for both ends of life. It increases in frequency 
from the equator toward the poles. It is recognized in forms acute 
and chronic, circumscribed and diffuse, ascending and descending, 
with varieties according to the character of the secretion and the 
condition of the bronchial walls ; but the division which has chief 
interest is into primary and secondary, the so-called idiopathic and 
symptomatic forms. 

Etiology. — It is easy to understand the origin of cases of primary 
bronchitis caused by the action of irritating or irrespirable gases or 
dusts. Individuals employed in factories for the production of am- 
monia, chlorine, iodine, bromine, or strong mineral acids show oc- 
casional attacks of bronchitis until the mucous membranes become 
habituated to the irritant. So, too, it is easy to understand bron- 
chitis or tracheo-bronchitis which results from the irritation of steam 
or dusts. Thus, engineers, bakers, millers, stone masons, miners, 
brushmakers, polishers, housemaids who are engaged much in 
sweeping, furnish another contingent of cases of bronchitis. But the 
vast majority of cases of primary bronchitis arise independently of 
all these conditions and are commonly ascribed to the process of tak- 
ing cold. 

Secondary bronchitis develops in consequence more especially of 
the infectious diseases. Bronchitis belongs to measles, small-pox, 
hay fever, typhoid fever, and constitutes an integral symptom of 
these diseases. Bronchitis is also frequently found in connection 
with diphtheria, universally in connection with tuberculosis, also 
almost universally, at least periodically, in association with asthma 
and emphysema. There is also more or less bronchitis in pneumonia 
and pleurisy. Inasmuch as bronchitis shows itself in the infections 



490 BRONCHITIS. 

in the first part of the malady, it is fair to assume that the cause of 
the disease lodges in the bronchial tubes. The acute exanthemata 
arise from a contagium vivum, and bronchitis is the first expression 
of the irritation of micro-organisms, as a diarrhoea results from the 
action of intestinal parasites. 

Secondary or symptomatic bronchitis occurs also in connection 
with mechanical disturbances of the circulation — that is, of nutri- 
tion of the bronchial mucous membrane. Bronchitis belongs to the 
later stages of heart disease, and shows itself in intensity in corre- 
spondence with the damage done to the heart. Thus bronchitis is 
more or less universal in tricuspid insufficiency. For the same rea- 
son bronchitis occurs in the course of cirrhosis of the liver or the 
kidneys. Every form of kidney disease which results ultimately in 
heart failure is attended with bronchitis. Bronchitis may arise also 
mechanically in the course of ascites or tumors of the abdomen of 
rapid course, which interfere with the action of the diaphragm. 

The bronchitis which belongs especially to the chapter of bron- 
chial catarrh is the malady which begins in the bronchial tubes, and 
which is ascribed to taking cold. " Catching cold " is really only a 
synonym for contracting disease, for bronchitis does not result from 
any change of temperature. Individuals plunge heated into a cold 
bath and emerge without bronchitis. Bronchitis is rare in the cold- 
est regions; it is almost unknown in the Arctic zone. So, also, bron-« 
chitis is almost unknown in the prairies, in the open sea, at the tops 
of mountains — places where the air is rare and cold ; not because the 
air is cold or rare, but because it is more pure. Colds are caught in- 
doors, not out-of-doors. It is safe to say that most cases of bron- 
chitis result from the action of micro-organisms of very great vari- 
ety. Thus it is known that typical bronchitis occurs in connection 
with tuberculosis and pneumonia. But that bronchitis may result 
from the action of micro-organisms indirectly, and be due rather to 
their products than their presence, is shown in the typical bronchitis 
of typhoid fever, which is caused by a bacillus that is never found in 
the bronchial tubes. Individuals who live in the out-door air, and 
who are subject to the greatest exposure, the most marked vicissi- 
tudes of weather, seldom suffer from bronchitis. Sailors have bron- 
chitis on shore, not at sea ; soldiers in barrack life ; inhabitants of 
cities rather than the inhabitants of the country. 

Geigel states that more illegitimate than legitimate children 
suffer and die from diseases of the alimentary canal, but that more 
legitimate children die of diseases of the respiratory tract. Illegiti- 
mate children die from neglect, bad food, and legitimate from cod- 
dling and confinement to the house, protection from every exposure. 
House air, as contaminated by closed windows, ill-ventilated com- 



ACUTE BRONCHITIS. 491 

partments, more especially by crowds in tenement houses, public 
assembly rooms, concerts, theatres, etc., schools and kindergarten, 
court houses and post offices, public buildings where men congregate 
and where the products of men accumulate — these are the breeding 
places of bronchitis. So the "cold" which is manifest on return 
from the theatre or ball room, if not present in latent form before, 
was caught in the room and not on the way home. 

One of the most valuable acquisitions of our day in reference to 
bronchitis is the frequency with which it is caused by, or is the 
manifestation of, tuberculosis. Many cases of tuberculosis never 
go beyond the stage of bronchial catarrh, which may show itself in 
exacerbations and remissions, the real nature of which is only dis- 
covered by an examination of the sputum, or more readily and surely 
by the use of tuberculin with the Koch syringe, after the manner 
specified in the chapter on Tuberculosis. Statistics, such as are 
furnished by oculists in the examination of the eyes of children, 
when brought to bear upon the examination of the sputum of the 
school room, the work shop, or the public hall, may alone show how 



* Fig. 217.— Koch 1 s syringe : action of piston substituted by rubber ball. 

widespread is the catarrhal tuberculosis which is now known in most 
cases simply as an innocent bronchial catarrh. 

Acute bronchitis shows but few morbid changes, however dif- 
fuse the disease or distressing the symptoms. The condition fades 
to leave no trace. The morbid anatomy of acute bronchitis is best 
studied during life, where it may be seen in the beginning of the 
bronchial tree. It has been abundantly observed that the same 
hypersemia and swelling of the bronchial mucous membrane extends 
into the bifurcation of the bronchial tubes and into the bodies of the 
tubes as far as can be seen. It is seldom possible to see much further 
than the bifurcation of the bronchial tubes. At this particular part 
the signs of inflammation are pronounced. There is more or less 
diffuse redness, distinct swelling, even tenderness to pressure from 
the outside, which pressure will at times beget an exceedingly irri- 
tating, prolonged cough. A tough, tenacious mucus covers the sur- 
face. In more chronic cases the mucous membrane is more distinctly 
hypertrophied, more especially discolored to assume a slaty hue. 
Pigment deposits are found more or less abundantly distributed 
throughout the bronchial mucous membrane. Patches of atelectasis 
occur in connection with the emphysematous process in the vicinity. 

Symptoms. — Scarcely any disease varies more in intensity than 



492 ACUTE BRONCHITIS. 

bronchial catarrh; from the slightest grades of inflammation, con- 
fined to the mucous membrane of the trachea and main branches 
of the bronchial tree, which hardly show any symptoms at all, 
at least in adults, to more or less universal involvement of the finer 
tubes, with more or less complete occlusion, and hence dyspnoea, 
suffocation, convulsions — the picture of capillary bronchitis, with all 
intervening grades of intensity. Thus the disease presents totally 
different aspects. Inflammation confined to the trachea and large 
bronchi furnishes, as a rule, in adults but few symptoms. Constric- 
tion, irritation, a sense of rawness, more especially a sense of tickling, 
usually relieved by a sharp cough which literally scratches the 
mucous membrane in this region, slight expectoration of tough, tena- 
cious mucus, few or no constitutional symptoms — this is the picture 
of ordinary bronchial catarrh as seen in adults. It does not in any 
way incapacitate the individual for work, or, as a rule, call for the 
use of drugs. In childhood and advanced life the picture may be 
quite different, even though the disease be limited to this region. 
The narrower calibre of the tubes in childhood produces a greater 
degree of stenosis, and the muscular failures of senescence lead to 
the accumulation of mucus, epithelial debris, etc., which may be 
aspirated in the deeper parts of the lungs, to lead here to symptoms 
of capillary bronchitis or catarrhal pneumonia. In childhood in 
these cases the cough is much more severe, the breathing more fre- 
quent, the distress from insufficient aeration of the blood more ap- 
parent. Duskiness of the face, cyanosis, somnolence, convulsions, 
coma, may occur in these cases, and are especially wont to occur 
where the individual is already debilitated by tuberculosis, syphilis, 
or rickets. The symptoms assume intensity in all cases as the dis- 
ease attacks the finer bronchial tubes, until finally, when it invades 
the finest tubes to produce the so-called capillary bronchitis, the case 
assumes the gravity of real catarrhal pneumonia. In fact, the diag- 
nosis between these diseases is well-nigh impossible. 

The lighter forms of bronchitis show no physical signs on in- 
spection. The chest movements are not inhibited. There is no- 
where any consolidation. The air still finds access to the recesses of 
the lung, so that auscultation may disclose no sign of the disease. 
This is especially the case in the tracheo-bronchitis of adults, which 
is revealed only by subjective signs, and more distinctly by the 
laryngoscope, when the lining membrane of the trachea may 
be seen to be inflamed, the disease concentrating itself more espe- 
cially at the point of bifurcation. Here, however, as elsewhere, "the 
tubes may be silent, so far as physical signs are concerned. In the 
middle-sized tubes the diagnosis often rests upon the physical signs. 
This is more especially true of the differential diagnosis. There is 
still no limitation of the excursions of the chest. The chest walls 



CAPILLARY BRONCHITIS. 403 

still rise and fall to the same degree as in the normal state. Men- 
suration shows no difference. No sign is yielded to percussion. 
Even slight lobular consolidations, more especially if central, may 
escape detection by percussion. All the more rich in signs is auscul- 
tation. As a result of thickening of the walls of the tubes, an ob- 
stacle is offered to the entrance of air. and coarse groaning, hum- 
ming, sonorous rhonch i pervade the chest. What distinguishes them 
as belonging to this disease is not so much their character as their 
distribution. They are heard not only below the clavicles, but over 
the whole of the anterior surface of the chest, in the lateral regions 
also, posteriorly, behind the clavicles and below. The dry rales 
are indicative of the stages of hyperemia and occlusion by the 
swollen mucous membrane. They give place, in the course of 
twenty-four to forty-eight hours, to moist sounds produced by the 
exudation of fluid. Every variety of moist sounds may be heard in 
the chest, from the coarse mucous rale to the finest crepitation. It 
is here, again, not so much the character of the sound as its wide 
distribution which is characteristic of bronchitis. The rales are sym- 
metrical ; they occur in both lungs ; they are confined to no parti- 
cular region of the chest. What again distinguishes them is the 
fact that they appear and disappear. A more profound inspiration 
or expiration, more particularly a sharp cough, may change the 
rales from moist to dry, or dissipate them altogether for a time; 
then they recur. The universality of the rales, their fugacity. 
their change in character, distinguish bronchitis from diseases which 
may show the same signs at certain periods or at certain places. 

CAPILLARY BRONCHITIS. 

Capillary bronchitis is recognized by the frequency of breath- 
ing, the respiration increasing to from 40 to 80 in a minute : by 
the increase in the fever, which shows temperatures ranging from 
102° to 105° ; by increase in the pulse rate, 160 to 180, in correspon- 
dence with the elevation of temperature. Notwithstanding the in- 
creased frequency of breathing, dyspnoea becomes more and more 
pronounced, the occlusion of the bronchial tubes leads to atelectasis, 
and the lung can now no longer follow the excursions of the chest. 
This limitation of movement becomes apparent with every act of in- 
spiration. The supra- and infraclavicular fossae, the intercostal 
spaces, the region about the insertion of the diaphragm, and the 
whole lower zOne of the chest retract and sink with every act of in- 
spiration. It is thus established that the lungs themselves, blocked 
in their bronchial tubes, remain more or less immobile. The defec- 
tive expansion is shown more distinctly in defective aeration of the 
blood. Cyanosis, which reveals itself first to the practised eye about 
the lips, spreads gradually over the face ; the finger nails assume a 



494 CAPILLARY BRONCHITIS. 

bluish tint. In the course of a few hours or a few days the extremi- 
ties, then the whole body, become more or less distinctly dusky or 
blue. The anxiety of the patient becomes intense. Hereupon en- 
sues the pitiable struggle for air, the silent, pain -inflicting appeals to 
relatives for relief. As the cyanosis increases the sensitiveness of 
the nervous system becomes gradually obtunded, the struggle for 
air is less pronounced, the condition of excitement gives place to 
apathy, and there is at this time an apparent but illusory improve- 
ment. Convulsions ensue at any time during this stage. Comatose 
states, sudden heart failures, put a merciful end to the scene. 

Capillary bronchitis is recognized for the most part by obtrusive 
signs. The frequency of breathing, the dyspnoea, the cyanosis, the 
fever, the nervous anxiety, above all things the retraction of the 
chest on inspiration, distinguish capillary from coarser forms of 
bronchial catarrh. In capillary bronchitis, which runs a more 
latent course, there is usually a history of catarrh which comes and 
goes, which seems more directly dependent upon the weather, which 
is present in the winter to disappear in the spring, or whose pre- 
sence or absence may be determined by change of residence. There 
is a cough, which remains unnoticed because of its long continu- 
ance. Old men have a " coughing spell " in the morning for years, 
and then are compelled to cough little or not at all during the rest of 
the day. They must expectorate the mucus which has accumulated 
over-night. The disease is more or less continuously present in these 
cases, but is subject to exacerbations and remissions ; and it is only 
when the exacerbation is attended by marked signs, as by increase 
of fever, violence of cough, pains in the limbs and joints, that the in- 
dividual will say he has caught a fresh cold and attention is di- 
rected to the disease. Not infrequently the disease is recognized by 
the conscientious physician, who makes a thorough examination of 
the body in the hope of discovering somewhere a latent cause for 
the symptoms of prostration. In other words, a capillary bronchitis 
in general has the same history as a catarrhal pneumonia. There 
may be in cases no dyspnoea, no anxiety, merely an increased weak- 
ness which confines the individual to his room, to his chair, to his 
bed, and of which the cause is not apparent. The physician ascer- 
tains that the pulse is quick, that the skin is dry, that there is fever, 
that the amount of urine is diminished, its specific gravity increased, 
and its color heightened, and he more or less suddenly comes upon 
the bronchitis in the course of his examination. The chest move- 
ments are feeble; respiration is more or less abdominal. The tape 
line reveals not more than an inch difference, if that, between inspi- 
ration and expiration. There may have been made a diagnosis of 
general debility from old age. Percussion shows no dulness, as a 
rule, though there may be strips of dulness along the spinal column 



CHRONIC BRONCHITIS. 495 

— proof that the disease has associated imto itself a catarrhal or a 
hypostatic pneumonia. 

Auscultation tells the story. A feeble, muffled, or absent vesicu- 
lar rale, sibilant or sonorous rhonchi, scanty, tenacious expectoration 
tinged with blood, make the diagnosis. We look for the disease in 
childhood in connection with measles, small-pox, and typhoid fever. 
It is not infrequently a sequel of diphtheria ; it belongs to tubercu- 
losis in all parts of its course. It assumes gravity in childhood for 
the reason, as stated, that the tubes are finer and the amount of 
swelling that would offer no appreciable occlusion in the adult lung 
produces stenosis in a child's lung. Then the tubes are shorter in a 
child's lung, so that diseased particles which would lodge some- 
where along the surface of the big tubes of the adult penetrate 
to the recesses of the child's lung. Both childhood and old age 
are more liable to bronchitis from the fact that the power of ex- 
piration and expectoration is less marked. There is not the same 
resilience in the lung substance itself, and there is not the same 
muscle force outside the lung, so that in both these cases infec- 
tions are liable to be introduced by aspiration from the mouth, from 
the throat, and from the larger bronchi. Mucus accumulates in the 
mouth and throat, mucus from the nose, epithelial debris, decompos- 
ing food; vomited matter, micro-organisms for which the mouth is 
a reservoir — all these materials may be aspirated into the recesses of 
the lungs, to produce first a bronchial catarrh, later even a putrid 
bronchitis or gangrene of the lung itself. 

CHRONIC BRONCHITIS. 

Chronic bronchitis occurs frequently as a result of the acute 
form of the disease, especially as the result of repeated attacks of 
acute bronchial catarrh, but much more frequently as a result of 
other affections of the lungs. Thus 'chronic bronchitis is a more or 
less constant conrpanion of emphysema, tuberculosis, and chronic 
pleurisy, especially in its purulent form, empyema, and still more 
frequently it results from diseases of other organs which interfere 
with the circulation in the lungs. Thus heart disease, kidney dis- 
ease, and diseases of the liver are attended at some time or other in 
their course by bronchitis, subacute or chronic. 

Chronic bronchitis distinguishes itself by its subacute character, 
not only as regards duration, but intensity of symptoms. Violent 
symptoms in its course betoken acute complications, to which pa- 
tients affected with chronic bronchitis are especially liable. The 
cough is not so frequent or severe, but continues over a longer time. 
Expectoration, on the other hand, may be much more abundant and 
different in many particulars. Dyspnoea is not, as a rule, so pro- 
nounced. It is a disease, however, which is by no means a trivial 



496 BRONCHORRHCEA. 

affection. It may be, and often is, followed by complications of 
gravity. Nearly all cases of long standing show some emphysema. 
The chief damage, however, is done to the heart as a result of long- 
continued cough and strain. There occurs hypertrophy of the right 
ventricle, which in time must result in degeneration, dilatation, and 
incompetency. There are present then cyanosis, oedema, dyspnoea, 
syncope attendant upon heart failure, with, in more protracted cases, 
oliguria, with the consequence of stasis of the kidney, somnolence 
or insomnia, headache, dropsies, and coma. So, while, as a rule, 
chronic bronchitis is not a disease of gravity quoad vitam, it has a 
more or less grave prognosis quoad valetudinem, and may in special 
cases, more especially cases debilitated by other disease, still more 
frequently in age, be attended, through its consequences, with fatal 
results. The fact is continually to be emphasized that chronic bron- 
chitis is rarely a consequence of acute bronchitis. It is mostly a 
secondary malady due to affections of other organs. 

Bronchitis is often divided into two forms, according to the 
abundance of its secretion. Thus there is a dry bronchitis, the ca- 
tarrhe sec of Laennec. This form of inflammation attacks more 
especially the finer bronchial tubes, where the same amount of swell- 
ing produces marked occlusion, and is characterized therefore by 
dyspnoea which seems out of proportion to the physical signs. There 
is no expectoration, there is sharp dyspnoea, more pronounced cya- 
nosis, anxiety, nervous unrest, and distress. This form of bronchi- 
tis is found frequently as a consequence, or in the course, of measles, 
whooping cough, and tuberculosis, and, because developing gradu- 
ally, is discovered more or less suddenly, especially in cases of apa- 
thetic, debilitated aged persons who have made no complaint that 
might call attention to the lungs. 

BRONCHORRHCEA. 

On the other hand, there is a form of bronchitis which is attended 
by such profuse expectoration as to merit the name bronchorrhcea. 
The discharge consists of thin, watery, frothy matter, which sepa- 
rates itself into layers. Pints or quarts of this fluid may be dis- 
charged in twenty-four hours. On rising from bed there is usually 
profuse expectoration of mucus that has accumulated over-night, 
more particularly in bronchiectatic cavities. The signs are not so 
distressing in this disease. There is no fever, there is little or no 
dyspnoea. The cough is not so harassing, because it is less con- 
tinuous and more paroxysmal, and relief follows the expectoration of 
a quantity of fluid. Patients affected with bronchorrhcea may main- 
tain a bien-etre for years ; the condition of health, however, in 
many cases becomes impaired daily, not infrequently because of as- 
sociated, if not causative, tuberculosis. 



BRONCHITIS PUTRIDA. 497 

BRONCHITIS PUTRIDA. 

A particular alteration occurs in the sputum of some of these 
oases, constituting what is known as a bronchitis putrida, or fetid 
bronchitis. Putrid bronchitis seldom occurs as a primary malady 
or in people in perfect health. It shows itself in the course of ordi- 
nary bronchitis, usually in the course of bronchitis secondary to 
other diseases. The patient is more or less suddenly attacked by 
chilly sensations followed by an elevation of temperature, and then 
in the course of a day the discharge assumes a peculiar and offensive 
odor, a kind of sweet, rotten odor, "that of the mayflower or apple 
blossom, with a kind of arriere-gout of faeces" (Laycock). The mat- 
ter separates itself distinctly into layers on standing — an upper lay- 
er, muco-purulent, frothy, with masses of more or less solid mucus 
from the coarser bronchi ; a middle, a scanty, greenish, sero-albu- 
minous fluid ; and a lower, more or less distinctly purulent sedi- 
ment, yellowish-green, the sediment consisting in large degree of 
smaller, more solid, caseous-looking masses, which Dittrich has shown 
to be expressions or casts of the finer bronchi, ' ' Dittriclrs plugs " 
— masses which crumble under pressure to emit that unspeakably 
offensive odor which makes the patient an object of disgust to him- 
self and every one else. One such patient will contaminate the air of 
a ward in a hospital, of a large room in a factory, or of a whole 
house. The odor may be recognized upon opening the front door. 
It is impossible to account for the sudden change which occurs in 
the sputum in these cases. It is eas}" to see that the sputum abounds 
with micro-organisms, fungi — Ley den speaks of a particular form of 
leptothrix — all the bacteria of decomposition, fat products, and crys- 
tals ; in fact, all the products of decomposition — sulphuretted hy- 
drogen, ammonia, fatty acids, leucin, tyrosin — may be discovered 
in this sputum. 

The disease is found in association at times with gangrene of the 
lungs, which makes itself manifest by the same offensive odor. But 
Traube has shown that the diseases are different ; wmile they may 
coexist, they are more frequently independent. 

Prognosis. — This form of bronchitis does not cease suddenly, 
as it began, but gradually, if it ceases at all. It is very obstinate 
to treatment. It shows itself in exacerbations and remissions for 
months, for years, sometimes for life. It might be supposed that 
putrid bronchitis resulted from the aspiration of products of decom- 
position from the mouth and throat into the lungs. Such an asser- 
tion may not be disproved, but it is a curious fact that individuals 
who work most with decomposing products, as tanners, scavengers, 
ragpickers, show no predisposition to it. It is, fortunately, the 
rarest form of bronchitis. 
32 



498 



FIBRINOUS BRONCHITIS. 



FIBRINOUS BRONCHITIS. 

A peculiar variety of bronchitis is the so-called fibrinous bronchi- 
tis, or bronchial croup. This affection develops in consequence of 
tracheal croup or croupous pneumonia, only as a very great excep- 
tion. As a rule the disease is secondary and occurs in the course 
of other affections of the lungs, chiefly in consequence of ordinary 
bronchial catarrh. The cause of this peculiar transformation is 
entirely unknown. The individual will have been, as a rule, in the 
enjoyment of his usual health, or that degree of it which belongs to 
ordinary bronchitis, when he is seized suddenly with chills or chilly 
sensations, to be followed by fever and symptoms of great distress on 





Fig. 218. Fig. 219. 

Fig. 218. — Fibrinous bronchitis. Cast expectorated with the sputum. 
Fig. 219.— Casts of the bronchial tubes expectorated in fibrinous bronchitis. 

i 

the part of the organs of respiration — that is, there is more or less 
dyspnoea, great constriction, profound anxiety, and feeling of im- 
pending suffocation, which indeed threatens and at times actually 
occurs. There is during the whole of the attack a most violent, 
harassing cough, which is attended in some of its explosive efforts 
with the discharge of casts of the bronchial tree. These casts alone 
establish the diagnosis. They may be recognized, often with the 
naked eye, as grayish- white masses of flesh-colored substances tinged 
with extravasated blood. They may be more readily distinguished, 
and are often only recognized at all, after immersion in water, when 
the branching of the bronchial cast is shown. They are thus dis- 



FIBRINOUS BRONCHITIS. 499 

tinctly casts of the bronchial tubes, and consist, in the smaller tubes, 
of solid masses of fibrin which have undergone hyaline transforma- 
tion, enclosing a large number of white blood corpuscles with a few 
red. The smaller casts are solid; the larger, hollow and composed of 
concentric layers. 

The sudden development of the disease with acute manifestations 
after chill and fever has led to the belief that fibrinous bronchitis 
is an acute infection, and analogy would place it in the same cate- 
gory with diphtheritic croup and croupous pneumonia, of whose 
infectious character there is no doubt. 

The disease by no means always occurs in this acute form, though 
much more frequently acute. The chronic form occurs also in the 
course of ordinary bronchitis, as a rule, but is distinguished by the 
milder character of the symptoms. It runs a course for the most 
part without fever, and is a malady consisting rather of exacerba- 
tions and remissions than of continuous course. It is distinguished 
in its exacerbations by the same signs of distress as the acute form, 
and is absolutely recognized only by the expectoration of casts of the 
bronchial tubes. Both forms occur especially in the young, between 
the ages of fifteen and thirty years, with exceptions, however, in the 
extremes of life. Kisch, for instance, reports the case of an indi- 
vidual aged sixty-six years who suffered from repeated attacks of 
fibrinous bronchitis, and who expectorated at times, over a period of 
twenty-five years, masses which looked like collections of coral. In- 
tervals of weeks or months, and sometimes even of years, with free- 
dom from symptoms, distinguish some of these cases. Bugge, who 
collected the statistics of ninety cases with special reference to cause, 
found that the great majority followed in the course of chronic bron- 
chitis and phthisis. 

The character of the casts frequently locates the affection. Casts 
from the upper portions of the lungs subdivide more rapidly as the 
bronchial tubes of this part of the lung rapidly grow shorter. Ordi- 
narily, bronchial casts are in their thickest portions about the size of 
goose quills, and subdivide gradually to the size of threads. 

The acute form of the disease has a very grave prognosis, inas- 
much as twenty-five to fifty per cent succumb within fourteen days. 
The mortality in chronic fibrinous bronchitis ranges about twelve per 
cent. Chronic fibrinous bronchitis distinguishes itself not so much 
by the intensity of its symptoms and its mortality as by its compli- 
cations. Emphysema, atelectasis, and catarrhal pneumonia ensue in 
a certain number of cases. 

The cause of this peculiar transformation of the secretion of the 
bronchial tubes remains involved in obscurity, and, as Kisch declares, 
the treatment, like the etiology, is as yet unexplored territory. 



500 



BRONCHIECTASIS. 



BRONCHIECTASIS. 

The last variety of bronchitis is that pathological alteration in the 
walls of the bronchial tubes which permits their dilatation, to consti- 
tute what is known as bronchiectasis. This condition was not 
known until the time of Laennec, for the reason, as he states, that 
dilatations of smaller tubes were considered as normal tubes of larger 
size, and great dilatations of larger tubes were looked upon as vomi- 
ca or cavities of phthisis. A closer inspection of the dilated tubes 
readily distinguishes them from normal tubes by their size at the 
periphery, inasmuch as normal tubes grow smaller gradually, tubes 
pathologically dilated terminate abruptly. Bronchiectasis occurs 
more frequently in the upper anterior portions of the bronchial tree, 
and concerns chiefly a few tubes of the third and fourth order. 
Tubes of the first order are never affected in this way. The disease 
is never primary, but occurs always in connection with other mala- 
dies, chiefly with long-standing chronic bronchitis, catarrhal pneu- 
monia, and more especially tuberculosis. Corrigan, in 1838, fur- 
nished the most satisfactory explanation of development of most 
cases in his description of the fibroid condensations that occur in the. 
lung, which were subsequently called interstitial pneumonia, later 
fibroid phthisis, and which we now consider to be relics, in all cases, 
of tuberculosis. The contraction of this hyperplastic mass of con- 
nective tissue, as in the process of cicatrization elsewhere, mechani- 
cally drags upon the tubes to force the deformity; and this deformhy 
is aided all the more by the fact that the bronchial wall itself suffers 
from lack of nutrition, interruption of its circulation, and consequent 
degeneration. The deformity occurs in various forms : the uniform 
enlargement with cylindrical dilatation, with fusiform or spindle- 
shaped dilatation, saccular dilatation, with such consecutive saccular 
dilatations as to constitute the beaded appearance, or with such sepa- 
ration of the dilated portions, with retention of their contents, as to 
form cysts in the lung — a very rare condition. 

The diagnosis of bronchiectasis is by no means always easy, for 
the clinical picture is that of the underlying condition of chronic 
bronchitis or tuberculosis. There are, therefore, all the v signs which 
belong to chronic bronchitis — cough, expectoration, interference 
with circulation, and dyspnoea, more or less pronounced. Somewhat 
more characteristic is the paroxysmal character of the cough and 
the discharge at intervals of large quantities of pent-up fluid. 
The mouthful or more copious discharges, however, speak for bron- 
chiectasis by no means positively, as abundant discharges, paroxysmal 
in character, are often seen in simple chronic bronchitis, and more 
especially in tuberculosis. Not infrequently, as is known, the dis- 



TREATMENT OF BRONCHITIS. 501 

charge from an abscess below the diaphragm, as from the liver, takes 
place in this way. 

Physical signs are not especially marked. The chest expands. 
There is no percussion dulness, except in the presence of a very 
large cavity. Auscultation reveals only the signs that belong to 
chronic bronchitis or tuberculosis. The differential diagnosis of 
bronchiectasis from chronic bronchitis rests more upon the discharge 
of large quantities of fluid — as a rule exceedingly offensive from de- 
composition — at intervals. These symptoms, which may occur as 
episodes in the course of bronchitis, belong to the regular course of 
bronchiectasis. Tuberculosis is distinguished by its more or less 
continuous fever, its progressive emaciation, haemoptysis, night 
sweats, etc., more particularly by the use of tuberculin, by the dis- 
covery of elastic tissue and the tubercle bacillus. Bronchiectasis has 
no definite duration. A developed deformity cannot be cured. The 
treatment is that of the underlying condition, upon the state or stage 
of which the prognosis rests. 

Treatment. — Acute bronchitis is best treated by rest in the 
house, preferably in bed, and the use of diaphoretics. Thus an 
acute cold may be often cut short by ten grains of Dover's powder 
at bedtime, or by a grain of opium in any other form. Diaphoresis 
is often pleasantly and profusely excited simply by warm drinks, 
especially if preceded or followed by a warm bath. Common green 
or black tea, taken hot and in quantity, is a diaphoretic as effective 
as any of the nauseating infusions of the old materia medica. 

In the acute bronchitis of childhood the warm bath plays the 
most important role, if given three or four times in the course of 
twenty-four hours. It is nearly always followed by peaceful sleep. 
Should diaphoresis fail, the treatment becomes purely symptomatic. 

In relief of the cough appeal is made to the expectorants. Chief 
among the expectorants in our day ranks apomorphine. A good 
prescription for a child is : 

R Apomorphinse liydrochloratis gr. ss. to gr. i. 

Acidi hydroclilorici diluti gtt. x. 

Syrupi fl. 3 ss. 

Aquae menthae piperita? fl. § iss. 

M. Sig. A half to one teaspoonful every two hours. 

Apomorphine is a very soothing expectorant, which acts like an 
anodyne, and, as has been proved by experiment, has real virtue as 
an expectorant. In bad cases of cyanosis and dyspnoea the remedy 
is best used subcutaneously in doses of one-twelfth of a grain, in- 
creasing the dose if necessary. It should not be used in old age. 
Ipecac in wine or syrup is a time-honored remedy, and, especially 



502 TREATMENT OF BRONCHITIS. 

in the form of the compound mixture, has a wide range of use. 
One grain of tartar emetic dissolved in a glass of cold water, of 
which a teaspoonful may be taken every hour, is an old and useful 
remedy. When the cough becomes very severe, and especially if it 
be associated with much pain, the necessity arises for the use of 
morphine, which may be incorporated with the apomorphine in the 
prescription above cited ; or the opium may be given in tincture, sim- 
ple or camphorated. Under no circumstances, however, should mor- 
phine be given to children. For an adult a prescription might read : 

R. Morphinae sulphatis gr. i. 

Aquae lauro-cerasi fl 3 ij. 

Aquse , q. s. ad fl. § ij. 

M. Sig. A teaspoonful every two, three, or four hours. 

The same relief, without risk, may be reached in children by the 
substitution of belladonna, which may be given, in the form of the 
tincture, in a dose of one drop for every year of the child's age. A 
few dry cups applied to the surface of the chest give great relief 
from pain at any age. Wet cups succeed when dry cups fail. Fly- 
ing sinapisms often suffice. Where pain is very severe, in exceptional 
cases, especially in childhood, a poultice may be put about the chest. 

For fever there is no remedy so good as quinine, which supports 
the heart while it attacks the fever. Many individuals learn to cut 
short a cold by a single dose of ten grains of quinine fortified by 
a drink of hot whiskey ; and whiskey or brandy is always a safe 
remedy to give to a child, with a smaller dose of quinine — never 
over five grains. Relief from fever is also given by the other anti- 
pyretics — antipyrin, which may be given to an adult in the dose of 
from three to five grains, a child one to two grains ; antifebrin in 
the same dose, or phenacetin in double the quantity. Phenacetin is 
the safest remedy. None of these drugs act so well in childhood 
as the warm bath ; and where bronchitis has become capillary, and 
dyspnoea assumes prominence or actual cyanosis has occurred, no 
remedy ranks in value with the hot or warm bath, and cold affusions 
to the head and chest while in the bath. Jurgensen has shown that 
a small stream of cold water directed to the nape of the neck will 
cause deep inhalations. A debilitated child will require additional 
stimulation in the form of senega, carbonate of ammonium, caf- 
feine, or digitalis. One drop of the tincture of digitalis every hour 
or two is at times invaluable. 

The treatment of chronic bronchitis varies more with the intensity 
than with the character or form of the disease. The remedies which 
are of real value are few. Prophylaxis merits discussion first. As 
already remarked, bronchitis is the most frequent of all diseases, and 
the greatest contingent of cases occurs in childhood. When we re- 



TREATMENT OF BRONCHITIS. 503 

gard the manner in which children are brought up, in closed apart- 
ments with defective ventilation, too warmly clad, for the most part 
not regularly bathed, in the ill-heated, ill- ventilated habitations that 
constitute what is known as the house climate, it cannot be wondered 
at that bronchitis, a disease which results from the inhalation of a 
contaminated atmosphere, is so frequent. We have also to regard 
here, as well as in the case of adults, the frequency of tuberculosis, 
which has bronchitis as its forerunner for months and as its com- 
panion for life. Rickets, too, is a disease which belongs to childhood, 
and which has bronchitis as one of its prominent and more or less 
constant symptoms. These three causes — vitiated house air, tuber- 
culosis, and rickets — account for the large majority of cases of 
chronic or constantly recurring bronchitis. In children bronchitis 
belongs, therefore, to those who are debilitated or diseased, and the 
factor of supreme importance in childhood is prophylaxis. 

It is needless to say at this age that a house can be well venti- 
lated, that sunlight and fresh air may be admitted, that the tempera- 
ture may be regulated, that the house may be kept dry. Children 
affected with tuberculosis, rickets, and syphilis must be treated for 
these diseases. Phosphorus, iodine, creosote, cod-liver oil, iron, qui- 
nine — these agents belong as much to prophylaxis as to treatment. 
Weak and debilitated children and adults are best inured by baths, 
which should be warm at first — 98° F. — then tepid, cool, and even 
cold, with brisk friction to the skin until the surface is brought to a 
glow, the perfection of the reaction being the indication of the grade 
of temperature for the next bath. Fresh air, exercise, a shorter stay 
in school, a better ventilated school room, are essentials in cure as 
well as prevention. The regulation of clothing, the avoidance espe- 
cially of heavy underwear, of mufflers and comforters about the 
throat, the exposure of the body until it becomes hardened like the 
face — these are means which must' be adopted gradually, that the 
body may become finally inured and, as it were, insured against 
bronchitis. A subject which deserves continued emphasis is the 
destruction of the sputum, which so often conceals the most danger- 
ous parasites. Cuspidors, with water in them, should be in every 
room. 

Old men are best protected by aA 7 oiding vicissitudes of tempera- 
ture, especially as connected with moist or windy days. On cold, 
wet days the old man should remain at home in his room — in the 
chimney corner, if not in bed. The circulation of the old man is to 
be sustained by another meal — if necessary, later in the night — by 
wine, brandy, or an extra cup of coffee or tea. Senile bronchitis 
may be avoided also by change of climate. Individuals whose cir- 
cumstances will permit should seek the warm, moist climate of 



504 TREATMENT OF BRONCHITIS. 

Florida, Southern California, the Bermudas, Nassau, or the dry, 
warm climate of Central Florida, Georgia, Aiken, Asheville, in the 
Carolinas. 

Chronic bronchitis requires more continuous treatment. In the 
dry form of chronic bronchial catarrh exudation may be furthered 
or forced by inhalations. The agent of most value in these inhala- 
tions is steam, and it is best generated by a steam atomizer. Simple 
atomizers without heat are of no value. The steam is given some 
additional solvent powers by the use of common salt, more particu- 
lar^ the bicarbonate of sodium in saturated solution, or disinfectant 
properties with carbolic acid, thymol, or boric acid. In capillary 
bronchitis steam is a necessity. Where the discharge is excessive in 
bronchorrhcea the best remedy is turpentine, which should be given 
in the form of capsules containing from five to ten drops. Cap- 
sules of turpentine are swallowed without taste with milk, or five 
to ten drops of turpentine may be dropped into a wineglass of milk. 
Finally, turpentine may be smoked for a long time in a pipe ; here, 
however, there may be evidences of idiosyncrasy, such as slight cere- 
bral disturbance and vertigo. A good substitute in these cases, or in 
any case, is terpin hydrate, which may also be given in capsule five 
to ten drops, or in pill one to two grains, three or four times a day. 
The balsams of Peru, tolu, copaiba, and sandalwood have virtue in 
individual cases. Cod-liver oil is food as well as medicine ; for chil- 
dren it is nicely compounded with malt. Many cases yield only to 
the prolonged use of iodine, which is best given in the form of iodide 
of potassium or sodium in peppermint water, in the ounce-to-ounce 
solution, beginning with from five to ten drops three times daily, 
largely diluted with milk. Its action is best suited to the cases 
complicated with asthma or dyspnoea. The best prescriptions for 
chronic bronchitis owe their virtue chiefly to the iodine they contain. 

Putrid bronchitis requires antiseptics, which may be inhaled from 
the atomizer, as suggested above. Terpin hydrate is here also of 
value internally. A most excellent remedy recently recommended 
is myrtol, which should be taken internally in doses of &ve to six 
grains. Myrtol acts through the blood; it may also be inhaled. It 
lessens the excessive quantities of sputum in putrid bronchitis and 
bronchiectasis, diminishes the offensive odor or destroys it altogether, 
and often in the course of a few days puts a new phase upon a dis- 
ease which has hitherto assumed alarming gravity. 

Bronchiectasis has no special therapy. No drug can restore tone 
to or contract the dilated bronchial walls. The treatment is the 
same as that for chronic bronchitis, and more especially "for putrid 
bronchitis, whereby disinfectant inhalations, more especially of ter- 
pin hydrate, menthol, and myrtol, play important parts. As has 



ASTHMA. 505 

been intimated, the diagnosis of bronchiectasis, or its differentiation 
from cavities in the lung from tuberculosis, is by no means easy. 
Moreover, inasmuch as these cavities are scattered throughout the 
lungs, there is none of that hope from surgical intervention which 
might be entertained where the affection is local. 

In all cases of chronic bronchitis, especially where chronic organic 
changes have occurred in the bronchial walls, such as excessive 
hypertrophies, atrophies, decomposition of their contents, and ecta- 
sias, there is necessity for support with alcohol. Senega and serpen- 
taria are considered good substitutes for squill, ipecac, and antimony 
in the debility of age. The carbonate of ammonium, best given in 
milk, is a remedy of value in advanced life or in extremis. The 
Germans have an anisated solution of ammonia which is a good 
preparation. Apomorphine is quick and pleasant, but not safe in age- 
A remedy which is of signal virtue in the chronic bronchitis of the 
aged, in the capillary bronchitis which ma}' not be separated from 
catarrhal pneumonia at either end of life, more especially in the 
chronic bronchitis of old age associated with heart failure and kidney 
suppression, is nitroglycerin, of which one or two drops of a. one-per- 
cent solution may be given every hour or two, or, to bridge over a 
sudden collapse, subcutaneously in doses of one to five drops. Ben- 
zoic acid is a fine stimulating expectorant. A failing heart calls for 
digitalis, tincture, gtt, v.-x. ever}" two to four hours. 

To sum up the therapy of bronchitis, the best remedy in the treat- 
ment of the bronchitis of childhood is the warm bath; the best remedy 
in the treatment of the acute bronchitis of maturity is diaphore- 
sis: for chronic bronchitis the remedy suggests itself with the dis- 
covery and treatment of its cause, whether tuberculosis, emphysema, 
heart disease, or disease of the kidney; the best remedy for senile 
bronchitis is support of the heart and change of climate. 

ASTHMA. 

Asthma (affSpiaZao, to breathe hard) : bronchial asthma ; ner- 
vous, essential asthma. — A paroxysmal dyspnoea caused by a peculiar 
catarrh with spasm of the bronchi. 

History. — The name of the disease dates from the period of 
symptomatic medicine, and the difficulty of breathing was a sign so 
obtrusive as to have fixed itself firmly in nosology. Hence asthma 
was a synonym for dyspnoea, and every difficulty of breathing that 
seemed due to obstruction in the chest was indiscriminately dubbed 
asthma. So forms of the disease multiplied with the effort to find 
place for various affections of the lungs and heart under this symp- 
tom. By the time of Sauvages (1768) there were no less than seven- 
teen species of asthma, a number reduced to eleven by Richter (1822)? 



506 ASTHMA. 

and gradually to two, idiopathic and symptomatic, in our own day. 
"Few terms have been so much abused in medicine or made to 
designate such different diseases" (Laennec). Though Willis and 
Cullen spoke of nervous asthma, it was not until the appearance of 
the paper by Ramadge (1835) and the prize essays by Bergson and 
Lefevre (1836) that asthma was really regarded as a neurosis of the 
respiratory organs — a view which seemed established by Romberg 
(1841), who based his conception of the disease, as a spasmus bron- 
chialis, upon the discovery by Reiseissen (1808) of muscular tissue in 
the finer bronchial tubes, and the contraction of these tubes under 
galvanization of the lungs by Williams (1840), and irritation of the 
vagus by Longet (1842). 

Whatever doubt still hung about the contraction of the bronchial 
tubes themselves would seem to have been finally dissipated by 
Lazarus (1891), who devised an ingenious apparatus wherewith he 
could, with the aid of curare and tracheotomy, experiment upon ani- 
mals in life, and whereby he produced the characteristic dyspnoea of 
the disease by irritation of the vagus nerve. 

Wintrich (1854) and Bamberger (1870) attributed asthma to 
spasm of the diaphragm; Biermer (1870) reinstated the disease in 
the bronchial tubes; Lebert (1873) believed in both factors; Weber 
( 1 872) invoked dilatation of the blood vessels and tumefaction, vas- 
cular turgescence with rapid exudation, a bronchiolitis exudativa; 
and Storck supported this view with laryngoscopic demonstrations of 
hypersemia of the larynx, trachea, and visible bronchi. 

Etiology. — Asthma has been reduced to two forms — idiopathic 
and symptomatic, or primary (essential) and secondary. But it is 
doubtful if there be such a thing as an idiopathic, essential asthma. 
Every year narrows more and more the number of idiopathic cases 
with the discovery of some cause, immediate or remote, to account 
for the attack of the disease. These causes may be grossly divided 
into mechanical, chemical, and reflex, whereby many cases may fall 
under more than one head. Thus, among the mechanical causes 
may be cited goitre, the so-called thymic asthma, aneurism, trauma, 
foreign bodies, dusts (pollen, etc., grinder's asthma), rickets, disease 
of the vertebrae (Pott's disease), disease of the heart (cardiac asthma), 
and certain diseases of the lungs, more especially bronchitis and 
tuberculosis. Under the chemical or toxic causes are renal, gastric, 
saturnine, mercurial, and malarial asthma, and the asthma produced 
by odors, also cases of arthritic and tuberculous asthma. Under the 
reflex causes are gastric, cardiac, sexual (especially uterine), intes- 
tinal (verminous), traumatic, and nasal asthmas. Finally, a small 
category of cases is to be attributed to psychic causes or ideas — 



ASTHMA. 507 

hysterical asthma. Most of these cases, it is plain to see, are cases 
of dyspnoea rather than asthma. 

The exact method by which asthma is produced by any of these 
causes remains as yet unknown. It is assumed that there is some 
irritation in the centre, in the course of, or at the periphery of the 
vagus, which excites the muscular tissue to contraction, so that the 
existence of an idiopathic form in our day implies a concealed cause. 
It is better to assume a cryptogenetic than an idiopathic origin in all 
cases, if only because one stimulates, the other stifles, inquiry. While, 
therefore, it may be doubted whether there is such a thing as an 
asthma as a pure neurosis — i.e., independent of an outside cause — it 
may be admitted that the sensitiveness of the nervous system differs 
in different people, and that certain individuals are more liable than 
others to attacks of asthma from the same cause. In other words, 
asthma implies unstable nerve cells of easy explosion, and takes its 
place in nosology by the side of epilepsy, insanity, migraine, etc., 
with which, indeed, it sometimes alternates. It is more in accord 
with modern medicine to look for the cause of the hyperesthesia of 
the vagus in irritations caused by micro-organisms— diplococci, for 
instance, tubercle bacilli, etc., or toxines — rather than in "heredity." 

Heredity plays a very insignificant role in the production of 
asthma. Age plays a more important role, in that, according to the 
statistics of Salter, of one hundred and fifty-three cases, one-fourth 
were under the age of ten and four-fifths under forty years. Sex, 
social position, and vocation have less to do with it. The disease 
occurs more frequently in males and in the luxurious upper class, 
but it is by no means rare among the poor. Teachers, clergymen, 
attorneys, people who lead sedentary lives, are rather more fre- 
quently affected. 

Since Cullen made the first observation of the development of 
asthma in an apothecary's wife whenever ipecac was powdered in 
the shop, similar cases have been reported by most observers. There 
is, however, an endless variety of materials which may evoke 
asthma in a patient born with the asthmatic tendency. Thus the 
smell of a sulphur match, pitch, smoke, hay, tobacco ; the rose, lily, 
and other flowers ; coffee and the odors of the kitchen ; odors of cer- 
tain animals (cats, rats, dogs, horses, rabbits, guinea-pigs, chickens) ; 
the odors of wild animals (as in menageries), precipitate attacks. 
Literature is full of curiosities in this regard. The proprietor of an 
equestrian establishment suffered from asthma continuously until he 
retired from business, when the disease ceased, to return, however, 
whenever he returned to his horses. Fagge speaks of the case of a 
lady who was affected whenever she came into a room in which was 
a cat, no matter where the animal was hidden. Kamadge tells the. 



508 ASTHMA. 

story of an employee in the East India Company who had to give 
up a lucrative appointment because the smell of tea developed an 
attack of asthma. Austin Flint was unable to sleep on a feather 
pillow. In one case the odor of roses brought on an attack, and so 
sensitive was this lady as to suffer a seizure on one occasion, though 
the rose which was held before her was artificial (psychic asthma). 

The frequency with which an explosion of asthma has occurred 
in consequence of real odors should have sooner led to the investiga- 
tion of the nasal cavity for sensitive areas. Voltolini long ago made, 
the observation that asthma may be produced by a polypus in the 
nose. In one of his cases removal of the polypus relieved the asth- 
ma, which returned with the recurrence of the growth, to disappear 
again with its extirpation. These observations have been abun- 
dantly confirmed by observers, many in our own land, first by 
Hanisch, and more lately by Hack, Roe, Harrison Allen, and Bos- 
worth ; so that at the present time the tendenc}* is to exaggerate the 
importance of the nasopharyngeal genesis of asthma, or to consider 
that the disease results exclusively from this cause. According to 
Schmiegelow asthma has a nasal origin in thirty per cent of cases — 
i.e., polypus twenty-two, rhinitis eight. Irritations about the lar- 
ynx, especially of the interarytenoid folds, are much less frequent 
causes. Glasgow made an interesting confirmatory observation of 
such cause by the accidental application of a concentrated solution 
of carbolic acid to the larynx for some local affection, when the asth- 
ma with which the individual had suffered severely for years disap- 
peared, never to return. 

Errors, more especially excesses, in diet frequently excite an ex- 
plosion of asthma. Attacks limited to certain days of the week can 
generally be traced to this cause. The peptic asthmas of the old 
writers were reflected indigestions, better explained in our day by 
gastric distentions and interferences with the circulation in suscept- 
ible subjects. 

Colds account for the many cases associated with bronchitis. 
These are the cases in which attacks occur after every exposure. 

Locality is a factor of etiology which cannot be overlooked. It 
has long been remarked — and the point was especially emphasized 
by Salter — that certain patients from the country get absolute ex- 
emption from an attack during a stay in the city. The immunity 
seems to be more assured or absolute as the air of the city is vitiated 
by soot and more especially by fog. London excels in this regard. 
Thus patients have come from the country to consult physicians in 
London, waiting for the development of an attack which never 
occurred, and have returned home in the belief that the disease was 
cured, to be attacked on the night of their return. And many 



ASTHMA. 509 

patients must make a regular habit of visiting the cities at stated 
intervals, or must make a permanent change of residence. 

Symptoms. — As a rule asthma sets in suddenly in the night, 
and, in the majority of cases, without the slightest premonition. In 
exceptional cases prodromata, as a sense of oppression or uneasiness 
about the chest, are felt on retiring. Certain individuals experience 
unusual health, a feeling of exaltation, the meaning of which ex- 
perience has taught them to understand. Usually the patient is 
awakened between midnight and morning, as with the nightmare, 
with a sense of terrible weight and, constriction about the chest. 
He is unable to breathe, and must at once arise in bed in efforts to 
secure inspiration. In bad cases the patient seizes the bedposts or 
the side of the bed, to get points of support for the auxiliary mus- 
cles of respiration : the face wears a wild, anxious look ; the sur- 
face becomes suffused and -dusky ; the ahe nasi play visibly ; the 
vessels stand out distended in the neck. The patient speaks as little 
as possible ; the speech is broken into syllables in economy of volun- 
tary effort. There is no cough and no expectoration. The patient 
declares that if he could cough he could clear his lungs. Later in the 
course of the attack, when the patient can find time to cough, there is a 
scanty sputum in clumps or masses which contain spirals, crystals, 
and eosinophile cells. 

The chest, notwithstanding the powerful action of the muscles, 
stands almost immobile at full distention. A superficial observa- 
tion reveals the fact that the main difficulty is with expiration. 
There is difficulty in getting air into the lungs ; to get air out of the 
lungs seems impossible. In bad cases the patient must get out of 
bed, fix himself in the kneeling posture beside the bed, or find some 
relative relief in standing, as at a mantelpiece with the elbows braced, 
or at an open window with the hands fixed on the uplifted sash, after 
methods found helpful in former experience. The descent of the dia- 
phragm protrudes the abdomen : the powerful contraction of the ab- 
dominal muscles makes it hard as a board. During the attack the 
distention of the lungs is recognized by the universal tympanites on 
percussion, which often develops, in consequence of the tension of 
the alveoli, the band-box tone. The heart sounds are muffied or 
suppressed by the coverin g lung. Auscultation reveals abundant 
sonorous and sibilant, later mucous or submucous redes, which 
drown all other signs. Finally, after the lapse of several hours, the 
breathing begins to grow easier, the patient falls into a deep sleep, 
and awakens in the morning weary, but nearly as well as before. - 
The attack repeats itself irregularly, sometimes on consecutive nights, 
sometimes not for several nights or a fortnight or more, usually with 
the occurrence of damp weather, and always with the development 



510 



ASTHMA. 



*~* tSh 




Fig. 220 



of bronchitis, to which the patient is especially liable. In the invete- 
rate cases the slightest exposure or imprudence precipitates attack. 

Crystals and Spirals. — Leyden (1872) made a contribution to 
differential diagnosis in the discovery in the sputum of certain crys- 
tals, angular, elongated octahedrals, which might be supposed to be 

the active irritative cause of the attack. 
These crystals are found in grayish masses 
in the sputum, varying greatly in size, col- 
orless or of a bluish tint, surrounded by 
masses of epithelium, and embedded often 
in certain peculiar structures known as spi- 
rals. Some of them are distinctly visible 
with the simplest lenses, but they vary so 
much in size as to be manifest, some of 
them, only with higher powers, as with a 
Hartnack No. 8. The crystals are insoluble in cold water, alcohol, 
ether, and chloroform, but are easily soluble in alkalies, mineral 
acid, warm water, ammonia, and acetic acid — which plainly allies 
them to mucin, a form of which Salkowski declares them to be. 
They are identical with the crystals, discovered by Charcot in 
semen ; which Klemperer has shown to be a phosphate of diethylen- 
diamin ; and by Neumann in the blood and mar- 
row of cases of leukaemia. They are most abun- 
dant during and after the attack of asthma. 
Friedreich and Zenker found them also in the 
fibrinous plugs of bronchitis, and Bizzozero and 
Von Jaksch saw them in bronchial catarrh 
without asthma. They have been observed also 
as confirmations in the f seces in cases of hel- 
minthiasis. Most interesting is the fact that 
Lewy found them in nasal polypi, but more 
especially in the pale-grayisH, gelatinous masses 
in patients not affected with asthma. He could 
not find them in the hyperplastic tissues or 
tumors encountered in certain cases of asthma. 

Leyden in the same year made the discov- FlG 
ery in the sputum of asthmatic patients of the spirals in the sputum of asth- 
certain peculiar spiral structures alluded to ma " 
above, which Curschmann later more fully described and advanced 
as characteristic of bronchial asthma. These spirals, the so-called 
Curschmann spirals, exist also in the grayish masses found in the 
sputum, often in connection, as stated, with the Charcot-Leyden 
crystals, in most frequent abundance at the beginning of an attack 
and in sharp, acute cases. They may be recognized even with the 



AlKfe 




Curschmann's 



ASTHMA. 



511 



naked eye in their largest size, but are better defined with the micro- 
scope of low power as elongated, spiral fibres grouped about a series 
of central and more open fibres, which present the appearance of a 
central canal. They exhibit, according to Yierordt, the finest forms 
of bronchial products, and hence correspond probably to catarrh of 
the smallest bronchial tubes (bronchiolitis exudativa). They are not 
exclusively present in asthma, but have been remarked also in croup- 
ous pneumonia and tuberculosis. These spirals also represent forms 
of inspissated mucus. They are, like the crystals, products, not 
causes, of a peculiar bronchial catarrh. 

It has been remarked that the spirals exist in greatest abundance 
at the beginning of the attack, when the crystals may be entirely 
absent, to present themselves in greater abun- 
dance later in the history of the disease. In- 
deed, crystals have been made to develop di- 
rectly from or in the spirals in sputum pro- 
tected for several days from evaporation. From 
the fact that both crystals and spirals have been 
found in other affections, they cannot be re- 
garded as pathognomonic evidence of asthma: 
but there is no doubt of the supreme value of 
these structures in differential diagnosis, for in 
any case of dyspnoea the existence of either 
crystals or spirals in the sputum speaks em- 
phatically for bronchial asthma. Revealed, as 
they are, by a glance under the microscope, 
search for them in a doubtful case should not 
be neglected. 

Further corroborative evidence is furnished 
by cell elements in the sputum. Muller demonstrated in the sputum 
of asthma numerous large lymphoid bodies, with pale-yellow pigment 
granules, which showed affinity or avidity for eosin — the eosinophile 
cells of Ehrlich. Lewy found these same cells in nasal polypi, espe- 
cially in the gelatinous masses with but little gland structure. 

Diagnosis. — True asthma is, as a rule, sufficiently easily recog- 
nized. The age of the individual, the time of its occurrence — i.e.. 
during the night — the suddenness of its onset, the intensity of the 
dyspnoea, above all things the difficult expiration, the sibilant and 
sonorous rhonchi, the great anxiety, the struggle for air — " Luft- 
hunger " — with the gradual cessation to complete relief and the free 
interval, the crystals and spirals and eosinophile cells, unmistakably 
stamp the disease. 

The diseases which simulate asthma are, first, affections of the 
larynx, spasm of the larynx, false membrane, and oedema of the 




Fig. 252.— Spirals with 
crystals in sputum of 
asthma. 



512 ASTHMA. 

larynx, to which may be added tracheal stenosis. But in all these 
cases the difficulty is with inspiration, not expiration. Inspira- 
tion is a long, powerful, stridulous struggle ; expiration follows easily. 
There are no wheezing sounds in the chest. The condition is often 
recognized with the laryngoscope. Spasmodic contraction of the ad- 
ductors or paralysis of the abductors shows the same inspiratory 
dyspnoea. Laryngismus stridulus is closely allied to asthma. It 
is also a neurosis with little or no associated catarrh. Paralysis of 
the posterior crico-arytenoid muscles is easily recognized with the 
laryngoscope. The vocal cords are found approximated, or separated 
by only a narrow chink. GEdema of the larynx occurs in conse- 
quence of acute laryngitis or of disease of the kidneys or lungs. 
Tracheal stenoses, unless due to foreign bodies, where the history is 
plain, are caused by neoplasms, syphilitic or carcinomatous, or by 
aneurisms, or by goitre — conditions readily recognized by simple in- 
spection or by evidences elsewhere in the body. 

Certain diseases of the lungs, more especially bronchitis and em- 
physema, resemble asthma in the fact that expiratory dyspnoea pre- 
dominates. It is often difficult to distinguish between asthma and 
emphysema because of their coexistence. Asthma produces emphy- 
sema, yet either may exist without the other. The emphysematous 
patient has the configuration and habitus of the chronic asthmatic. 
The dyspnoea is more or less continuous; it is aggravated by ex- 
ercise, excitement, emotions. Its exacerbations, which simulate 
asthma, attack the patient more, therefore, when he is awake. True 
asthma occurs for the most part in sleep. Crystals and spirals, eosin- 
ophile cells, rare in emphysema, occur as a rule in asthma. Inter- 
mission is the rule of the dyspnoea in asthma, remission in emphy- 
sema. 

Bronchitis distinguishes itself by its more gradual, never sudden, 
onset; by its more abundant cough and expectoration, which, at first 
mucous, may become purulent — a change which never shows itself 
in asthma. In bronchitis the wheezing sounds, although sometimes 
universal, are confined more especially to the posterior inferior lobes 
of the lungs. They are never so intense as in asthma. There is 
more or less fever — absent in asthma — in acute diffuse bronchitis, 
which form alone resembles asthma. 

Dyspnoea from heart disease closely simulates asthma at times. 
Here too, however, the dyspnoea is more strictly dependent upon ex- 
ercise or cardiac activity. In cardiac dyspnoea there is evidence of 
heart disease. There are valvular murmurs, accentuations, hyper- 
trophies, especially dilatations, and other evidence of incompetence, 
irregularities in rhythm, general dropsies, scleroses of vessels, etc. 
The dyspnoea may become profound in cardiac disease, more espe- 



ASTHMA. 513 

cially in the later stages, in consequence of oedema of the lungs. 
OEdema of the lungs does not, however, show the same degree or the 
same kind of dyspnoea. Respiration in it is more shallow and super- 
ficial. It is not so much a question of obstruction as of infiltration. 
The expectoration is more profuse, watery, and is often tinged with 
blood. 

Spasm of the diaphragm shows quite a different picture. There 
is a sudden, abrupt inspiration, often attended with hiccough and 
forcible fixation for a few seconds, then a quick, violent, expulsive 
effort. Spasm of the diaphragm is best seen in tetanus. 

Intercostal neuralgia, which restricts the action of the respiratory 
muscles, may be distinguished by its painful points and by its pain in 
general. There is no wheezing, no cough, no expectoration. 

Embolism of some of the branches of the pulmonary artery 
sometimes resembles asthma. Embolus is found in connection with 
heart disease. Respiration becomes suddenly irregular. There is 
intense anxiety, often expectoration of blood, profound dyspnoea — 
which differs from asthma in affecting both inspiration and expira- 
tion — marked prostration, and not infrequently sudden death. Often 
there is evidence of embolus elsewhere. 

Renal asthma is found in connection with B right's disease with 
its distinctive signs. 

The treatment of asthma resolves itself into two problems: to 
cure or cut short the attack and to prevent its recurrence — i.e., to 
treat the paroxysms, and to treat the patient in the intervals between 
the paroxysms. 

1. The patient should be placed first in a comfortable position, 
which, in fact, he finds himself. There should be allowed the same 
latitude of disposition of the body in the paroxysm of asthma as in 
the pains of parturition. Tight clothing should be loosened, free 
ventilation secured, officious ministrations avoided. To sit up in 
bed with the elbows on the knees elevates the shoulders from the 
chest and gives additional points of support to the auxiliary muscles 
of respiration. This posture is usually taken at once. Many pa- 
tients get this relief sitting in a chair with the elbows supported upon 
its arms ; others kneel, with the elbows upon the chair or side of the 
bed, or seize the framework of the bed, or stand with the hands 
grasping the mantel or the elevated sash of the window. Individ- 
uals have found some comfort by supporting the shoulders on 
short crutches by the side of a chair, and various apparatus have 
been devised, armchairs with special supports, or head bands and 
shoulder supports swung from the ceiling — different postures for 
different individuals. 

Should the attack be clearly due to indigestion, stomachic or 
33 



514 ASTHMA. 

intestinal, the quickest means of relief is by an emetic or an enema. 
A cardiac or a renal asthma is often quickest relieved by a hot bath. 
Offensive odors, animals, flowers, feathers, drugs, should be removed 
at once, or the patient may be removed from their vicinity. The 
mere lighting up of a dark room at night suffices at times to relieve 
an attack, as was the case with Trousseau. 

Inhalations. — The fumes of saltpetre have been used for half 
a century, and probably no single remedy has so wide a range of 
utility. It is, as Salter remarked, always a matter of surprise to 
learn that an individual has not tried this drug. Often it fails from 
improper use. The patient may make the solution himself, or buy it 
prepared, alone (chartse potassii nitratis), or with other drugs. Or- 
dinary blotting paper, not too thin or too thick, is dipped in a warm 
saturated solution of saltpetre, dried, cut in squares or strips, and 
ignited, the patient breathing the fumes as they rise. The room 
should be small — a closet with a partly opened door, a seat under an 
umbrella, or a tent of bedclothes over a chair to substitute the cur- 
tains of the old four-posters. It may be inhaled in any desired 
strength from, under a funnel. If it is to act at all it acts quickly, 
usually exciting some cough at first; breathing becomes easier in 
a few minutes. Patients use it also as a preventive, inhaling the 
fumes for a few minutes before retiring or just after retiring, or they 
leave the strips in easy reach to be ignited with the first manifesta- 
tion of symptoms. There are patients who prefer not to go to bed 
at all than to have to dispense with the fumes of nitre. It should be 
used at the very beginning of the attack. Sometimes it gives but 
partial relief; sometimes it succeeds at first and fails later; sometimes 
it fails utterly. The potassium nitrate parts with oxygen readily, 
and it is believed that its virtue in asthma is due to the nitrite which 
is left. The older practitioners used it also freely internally in doses 
of twenty grains, with twenty or thirty grains of the potassium 
carbonate, in a tumbler of water three or four times a day. 

Stramonium is a still older remedy, having been introduced from 
India in 1802. The stramonium most used in our country is the 
leaves of the common Jamestown weed dried and ignited, or prefer- 
ably rolled in the form of a cigarette. Stramonium may reach cases 
in which nitre fails. The converse is more frequently true. Stra- 
monium is a more dangerous remedy. The danger is obviated by a 
cessation with the first confusion of sight or intellect. Both nitre 
and stramonium sometimes fail completely. They are more likely 
to succeed in toxic or purely bronchial cases, and fail in every way 
in nasal or naso-pharyngeal cases. 

Coniine, hyoscyamine, and hyoscine are remedies which have 
been used as substitutes for stramonium, but they succeed only in 



ASTHMA. 515 

the most exceptional cases and in the face of greater dangers. More 
may be claimed for atropine. Belladonna was the favored remedy 
of Trousseau, who recommended that it be used for a long time with 
occasional intermissions. Belladonna relaxes spasm. Lenhossek, 
Harley, Salter, each advocate it strongly. Its best effects are ob- 
tained when used in a grain-to-the-ounce solution, beginning with 
from two to five drops and pushed gradually to tolerance. It should 
be given at bedtime, to anticipate the onset of the disease in the early 
morning. 

The remedy which has the most sovereign control over the great- 
est number of cases is morphine subcutaneously. Morphine rarely 
fails to abort an attack of asthma. It should be given in doses of 
gr. i~i. Some of its evils may be counteracted by admixture with 
atropine gr. too - rib"- Morphine would be used universally, were it 
not for its unpleasant after-effects. It nauseates some patients and 
disturbs the digestion of nearly all patients. It produces discomfort 
for the whole of the following day. Most patients prefer rather to 
suffer an attack of asthma during the night than to endure the dis- 
comforts of morphine and disqualification for work for the whole of 
the following day. Then, too, morphine has the disadvantage that 
it soon begets tolerance. The dose must be gradually increased. 
There are authors who maintain that it is better to suffer the evils of 
morphine than the damage which protracted paroxysms of asthma 
produce. There are individuals who learn to use the remedy only in 
the worst attacks, and thus are not obliged to increase the dose. 
Stevenson in five years never increased the initial dose over one-sixth 
of a grain, with uniform success. It is not good practice to resort 
regularly to morphine; morphine is to be used as a dernier ressort. 

Next to morphine — in the estimation of many practitioners, far 
above it — stands chloral, which often, indeed, "acts like a charm.'' 
Chloral is given in large doses — givxv.-xl. largely diluted — at once 
rather than in small doses frequently repeated. It acts quickly, re- 
laxes the spasm, and gives the indescribable relief of a full breath in 
the course of five or ten minutes. No remedy has received higher 
praise; no remedy is more satisfactory in most cases; no remedy fails 
so utterly in many others, for when it fails it aggravates the case. 
It acts best in those cases which seem to be more strictly idiopathic. 
It acts worst in heart disease, where it is even dangerous. It is 
certainly not good practice to resort indiscriminately to chloral. The 
drug does not deserve the praise lavished upon it a decade ago. It 
falls short, if only because it fails to address the cause. It leaves the 
nervous system weaker than before. Yet both morphine and chloral 
are indispensable in certain cases. The practitioner must decide for 
the individual case. 



516 ASTHMA. 

To most patients relief, sometimes absolute, more frequently par- 
tial, but relief enough for sleep, is furnished by some one of the antipy- 
retics — antipyrin, antifebrin, phenacetin, or quinine. For an adult 
there is usually required at a dose of antipyrin gr. x. , of antifebrin 
gr. v. , of phenacetin gr. xv. , of quinine gr. x. ; and one such dose at 
bedtime or at the beginning of the attack will, as stated, usually 
suffice at least to modify the attack. Quinine gr. v.-x. at bedtime 
is, as a rule, the better remedy. 

Chloroform acts more quickly than chloral, and there is no case 
that will resist inhalations of this drug. Unfortunately the good 
effects of chloroform do not persist. The symptoms return after the 
cessation of its use. Where patients are compelled to use it for them- 
selves, four or five drops should be let fall upon and inhaled from a 
handkerchief. Other anaesthetics of equal or nearly equal value are 
ether, iodide and bromide of ethyl, nitrite of amyl, and pyridin. All 
these remedies are to be inhaled in the same way from a handkerchief, 
except that pyridin is better administered by being poured — a dozen 
drops — upon a hot plate and inhaled in a small room or closet. It 
may be said of all these succedanea that they are of value only in 
the milder cases and that they will fail entirely in the majority of 
€ases. And it may be said of chloroform that, while it may be in- 
haled in small quantities without danger, it becomes so dangerous in 
large quantities, often in sufficient quantity, and of such temporary 
value in all quantities, as practically to exclude its use. 

In the case of fatty heart, where there is decided contra-indica- 
tion to chloral, paraldehyde has been used as a substitute, best ad- 
ministered with the tincture of orange peel. 

Tobacco is a drug that has no superior in persons not accustomed 
to its use. The profound nausea caused by the smoking of tobacco 
stops asthma like the wave of a magician's wand ; and this may be 
said of any agent that has the same effect, as of antimony and lobe- 
lia. Nausea is the enemy of asthma, as of any other spasm. Un- 
fortunately the remedy cannot be used by most males because of 
tolerance, and by most people because of the extreme distress of 
intense nausea. There are individuals, however, who have learned 
to smoke to protect themselves against asthma, and who have re- 
mained free from the attacks so long as they have used tobacco. 
But it is true of the majority of cases that the asthma will assert 
itself so soon as tolerance is established. Most patients prefer the 
distress of severe asthma to intense nausea, and are driven to eme- 
tics — ipecac by preference — only because experience has taught them 
the futility of everything else. 

Mental emotions, a shock, a sudden surprise, excessive joy, grief, 
fright, a cry of fire, may cut short an attack at once. Knight tells 



ASTHMA. 51? 

the story of an asthmatic who was relieved at once, in playing cards,, 
so soon as the stakes grew high. 

2. The success of the treatment of the interval, the prevention of 
the recurrence of the attacks, depends on the cause. In a certain 
percentage of cases the cause may be discovered in the nose, and re- 
moved by the use of astringents, emollients, boric-acid ointments, 
more especially caustics, chromic acid, trichloracetic acid, above all 
the gal vano- cautery. The extirpation of polypi, the reduction of 
hyperplastic tissue, the destruction of sensitive areas, as localized 
often by ten- to fifteen-per-cent solutions of cocaine, have been fol- 
lowed by results as satisfactory as could be desired ; this, too, in cases 
where other treatment has been tried for years. Adenoid growths 
in the naso-pharynx, affections of the tonsils, cicatrices, ulcers, vari- 
ous affections of the pharynx, more rarely of the larynx, tra- 
chea, and bronchi, have all served as excitants of the explosions of 
asthma. 

The remedy which enjoys the highest repute in the treatment of 
asthma in general, without reference to discoverable cause, is the 
sodium iodide, or, preferably, the potassium iodide, in gradually in- 
creasing doses. The patient may begin with ten drops of the ounce- 
to-ounce solution (peppermint water), and increase it to intolerance 
as manifested by coryza, with, in most cases, the most beneficial 
results. Of all the remedies which have been used in asthma 
none deserves so much praise as the iodides, probably because they 
address a hidden cause, which may be enlarged glands, cervical or 
bronchial, irritating the vagus nerve. Every practitioner may re- 
call individuals who remain free of attacks of asthma so long as they 
are under the influence of an iodide. It is the remedy which is to be 
tried the first and longest. Large doses are best administered in milk. 
It is a rare case of pure nervous asthma which is not at least bene- 
fited, and many cases are actually cured, by the persistent use of the 
drug. 

Next is arsenic, which should also be given in gradually increas- 
ing doses up to the point of tolerance ; then reduced, and continued 
in smaller dosage over long periods of time. Arsenic has manifold 
testimony as to its virtue. It was the remedy most relied upon by 
the older practitioners. Quinine is of signal value in individual 
cases. It is best adapted to those varieties of the disease which show 
some periodicity or recurrence. 

Leyden, finding that the crystals found in the sputum of asthma 
were soluble in the chloride of sodium and carbonate of sodium, 
recommended the inhalation of one part of each of these agents in 
one hundred parts of water, twice daily, in the form of spray. Fauth 
says that the carbonate of ammonia liquefies the spirals. He finds 
it of value, therefore, in the therapy of asthma. Little could be 



518 EMPHYSEMA. 

expected from the use of this remedy with our present knowledge 
of the relation to asthma of these structures. 

Salter speaks highly of the use of alcohol in certain cases. It 
must be given hot and strong to be of any effect. Saturation with 
the bromides, as in the treatment of epilepsy, is an efficacious treat- 
ment in aggravated cases. 

It has already been intimated that many patients are relieved ab- 
solutely by change of climate. In this regard also asthma has its 
freaks. Patients in the country are relieved in the city, and vice 
versa; patients in valleys by mountain air, and patients in the moun- 
tains by descending to the valleys. A moist, humid air will relieve 
most patients. Asthmatics are more often benefited at the seaside 
than in the mountains. So capricious is asthma that change of sleep- 
ing .apartments from the ground floor to the upper story, or vice 
versa, may have the same preventive effect. The truth is, the 
patient must find his own climate, must sometimes make changes, 
and must remain as long as he may in the climate which is best for 
him. Florida, Southern California, the Bermudas, Nassau, the sea 
or its coast, and the inland lakes are points of selection. 

Oxygen and compressed air are other resorts in the treatment of 
this disease. Patients are made to inhale compressed air in apart- 
ments or portable apparatus for hours at a time — sometimes to 
effect a cure, oftener to give temporary relief, often to fail entirely. 
As a general rule it is best to inhale compressed air and exhale into 
rarefied air. Those cases are most benefited which are most depen- 
dent upon bronchial catarrh. Asthma per se is little or but tempo- 
rarily affected by pneumatic therapy. 

The induced current of electricity — electrodes at the inner border of 
the sterno-cleido muscle, and sessions of from ten to fifteen minutes 
— has met with renewed advocacy by Schmitz, and has proven of 
value in exceptional cases. 

EMPHYSEMA. 

Emphysema (sjj-cpvGrjpia, inflation) of the lungs. — Inflation, dila- 
tation of the air cells, with characteristic deformity and dyspnoea. 

History. — Definite knowledge begins with Laennec (1819), who 
gave the disease a name and distinguished two forms, the alveolar 
and interlobular, according as the air was found in the air cells or 
between them in the interlobular tissue. Laennec ascribed the dis- 
ease to bronchitis, which permitted the ingress but prevented the 
egress of air, and thus dilated the air cells — the inspiration theory. 
Mendelssohn derived the pressure from expiration, basing his view 
upon the fact that efforts, as in labor, at stool, blowing instruments, 
especially with cough, distend the air cells. Gairdner developed 



EMPHYSEMA. 



519 



the condition from the extra work thrown upon certain parts of the 
lung on account of occlusion of other parts — compensatory emphy- 
sema. Kokitansky attributed the disease to nutritive changes, espe- 
cially weakness of the elastic tissue, which permitted dilatation. 
Modern authors select one, especially the last, or unite several, of 
these views to account for the lesions of the disease. 

Etiology. — Hard work, heavy straining, long labors, especially 
frequent and protracted paroxysms of coughing, furnish the condi- 
tions which develop emphysema. So emphysema may result from 
whooping cough, more frequently 
from bronchitis, and more espe- 
cially from capillary bronchitis 
with asthma. 

Compensatory or vicarious 
emphysema develops in connec- 
tion with, or as a result of, dis- 
eases which interfere with the 
expansion of the lungs — occlusion 
of the bronchi, adhesions of the 
pleura, pneumothorax, ascites, de- 
formities of the spinal column. 

Interlobular emphysema re- 
sults from rupture of air cells and 
escape of air into the interstitial 
tissue. Such rupture implies 
natural defect and violent effort, 
as in whooping cough, capillary 
bronchitis, dyspnoea. 

From the nature of the avoca- 
tion, males are affected more fre- 
quently than females; and, on account of the changes in nutrition, 
middle and advanced life more than youth. 

Symptoms.— -The disease is subacute and chronic, and is an- 
nounced insidiously with a growing sense of constriction, dyspnoea, 
palpitation of the heart, which shows itself at first only after effort 
or cough, and gradually increases in degree to be, with exacerbations 
and remissions, more or less continuous. 

Changes of climate, exposure to cold, errors in diet, any impru- 
dence or extra effort, aggravate the disease. Asthmatic attacks 
soon supervene ; the heart's action grows feebler, the extremities 
cool, the veins stand out in the neck, the muscles of the neck are 
hypertrophied ; the chest is dilated in all directions, it begins to 
hide the neck so that the head comes to rest upon the shoulders, and 
the chest assumes a distinct barrel shape. Defective inspiration 




Fig. 223.— Emphysema pulraonum: a, dilated 
ialercapillary space with epithelial cell ; 6, 
empty spaces in alveolar wall ; c, obliterating 
vessel ; d, great defect in alveolar wall with 
still greater defect of capillaries (Ziegler). 



520 EMPHYSEMA. 

leads to defective circulation, which shows itself in the signs of 
stasis — to wit, oedema about the ankles; oliguria, albuminuria, later 
parenchymatous nephritis with casts ; hypertrophy and dilatation 
of the right ventricle, announced by accentuation of the pulmonary 
valve sound and pulsation in the epigastrium; later, duskiness of 
the face and cyanosis. Catarrh of the stomach, constipation, icterus, 
belong among the symptoms of digestive disturbance. Aggravated 
cases are marked by accumulation of fluid in the serous sacs, and 
anasarca. 

Inspection reveals the external conditions — cyanosis, especially 
of the lips, ears, finger nails ; ectasias of the finer vessels of the 
face ; pulsation of the jugular, the bulb of which protrudes, in 
coughing, a sac as big as a thumb (Fleischer). The skin is mottled 
and shining. The auxiliary muscles of respiration are hypertro- 
phied. The distention of the lungs in every direction elongates and 
dilates the thorax to the cylindrical or barrel shape. The heart is 
depressed and often concealed by the overlapping lung, so that its- 
impact may be no longer felt. The diaphragm, with the abdominal 
viscera, is pushed upward. The dulness of the liver reaches to the 
umbilicus. 

The conditions revealed by inspection are still more manifest to 
palpation, which may better appreciate the defective excursions 
of the chest, diminished or absent impact of the heart, and dimin- 
ished vocal and pectoral fremitus. Mensuration more accurately 
marks the diminished expansion. The difference between inspira- 
tion and expiration, which should amount to three or four inches, 
is diminished to two inches or less. Sometimes, under the most 
powerful effort, the chest is not expanded at all. 

Percussion yields a peculiar resonance on account of the disten- 
tion of the alveoli and tension of the chest — the so-called band-box: 
tone of Biermer. Auscultation shows an enfeebled vesicular rale. 
Inspiration is shortened. Expiration is scarcely to be heard at alL 
Bronchitis, which is associated with emphysema as a rule, espe- 
cially with exacerbations which bring the patient to the physician, 
drowns every thing else with its own peculiar sounds. 

The diagnosis is determined by physical examination. The 
symptoms, which are closely simulated by asthma, are separated by 
the fact that asthma occurs in paroxysms, with intervals of com- 
plete freedom. Emphysema, though it varies in degree, is more or 
less continuous. Heart disease, cardiac dyspnoea, is distinguished 
by the history of the case, especially by preceding rheumatism, and 
signs of valve lesion or muscle weakness. 

The prognosis is always serious. The disease is organic, and, 
when chronic or pronounced, incurable. The comfort of the patient 



CATARRHAL PNEUMONIA. 521 

depends upon his surroundings. The individual who is compelled to 
work for a living has a hard fate and a short life. The patient in 
position to secure exemption from effort and change of climate 
longest postpones damage to the heart. Complicating bronchitis, 
asthma, especially pneumonia, intensely aggravate the prognosis. 

The prophylaxis is protection against attacks of bronchitis, asth- 
ma, whooping cough, etc. , regulation of the habits of life, especially 
with regard to exercise in the open air, the avoidance of errors in 
diet, exposure to cold, attention to the bowels, etc. 

The treatment resolves itself into the treatment of the accom- 
panying bronchitis, relief of strain upon the lungs, and support of 
the heart. 

The treatment of bronchitis and asthma has been sufficiently re- 
marked. The heart is best supported by small doses of digitalis, 
which may be given in the form of the tincture, five to ten drops 
three or four times a day ; or the infusion, teaspoonful to a table- 
spoonful every three or four hours; or the powder of the leaves, 
one or two grains with twice as much white sugar. The further 
treatment of heart disease and cardiac complications is discussed in 
connection with these affections. The only treatment which may be 
called specific is that of pneumatotherapy. Patients are made to 
inhale, with an appropriate apparatus (Heuck's, Williams', Walden- 
burg's), compressed air, and exhale into rarefied air. Change of 
climate accomplishes most. 

croupous pneumonia (see Infections). 

CATARRHAL PNEUMONIA. 

Catarrhal pneumonia, broncho-pneumonia, lobular pneumonia. — 
Catarrhal inflammation of the capillary bronchi and air cells, charac- 
terized by irregular fever, cough, dyspnoea, increase of respiration 
and pulse, disturbance of pulse-respiration ratio, carbonic-acid poison- 
ing, indefinite duration, grave prognosis. 

Neither the older anatomists nor the clinicians were able to dis- 
tinguish that form of pneumonia which occurs in consequence of the 
extension of a bronchitis. None of the older writers mentioned a 
pneumonia in consequence of measles. The recognition of catarrhal 
pneumonia dates from the special studies of diseases of children. To 
Barthez and Rilliet is generally ascribed the credit of having first 
recognized this disease. The term is not very appropriate. The 
word catarrhal is used in distinction from croupous, with the under- 
standing that the catarrhal process means an affection of the mucous 
membrane with exudation of mucus and, at the most, pus, whereas 
the croupous exudation is blood, fibrin, or transformed epithelium. 



522 



CATARRHAL PNEUMONIA. 



Neither term is likely to survive a definite understanding of the na- 
ture of both processes. 

The distinction is often made between lobar and lobular pneumo- 
nia, understanding by lobular an inflammation which is confined to 
individual lobules bnt does not extend to involve an entire lobe. In- 
asmuch as the disease is always a secondary process and occurs in 
consequence of or as a result of bronchitis, the proper term for the 
disease is broncho-pneumonia. It should be understood from the 
start that a broncho-pneumonia does not exclude a croupous pneu- 
monia. The processes not infrequently coincide, and the question is 
often one of predominance. Cases which are considered catarrhal 
resolve themselves not infrequently as croupous pneumonias, and, 
more rarely, cases which bear the aspect of croupous pneumonia 
turn out to be catarrhal. As a rule, however, the diseases may be 
distinctly set apart. 

Some of the best pathologists and clinicians already subdivide 
cases of lobular pneumonia. Thus Fiedler distinguishes a broncho- 
pneumonia and a cellular pneumonia. The cellular pneumonia is 
not secondary to bronchitis, but springs up of itself in the air cells. 
The pneumonia of influenza is the typical cellular pneumonia. These 
various pneumonias are best distinguished by their etiology, the study 
of which explains also their relation to each other. Thus in Fiedler's 
fifty-five cases, in which the examinations were made by puncture of 
the lungs in life, the cause was found to be as follows : 



Diplococcus pneumoniae Frankel's 
Bacillus pneumoniae, Friedlander . 

Staphylococcus 

Streptococcus 



Fibrinous 


Broncho- 


pneumonia. 


pneumonia. 


15 


4 


2 


1 


2 


4 


4 


4 



Cellular 
pneumonia, 



2 

1 

12 

27 



In five cases no bacteria were found. These findings coincide in 
the main with those of Weichselbaum. 

Etiology. — Croupous pueumonia begins as such. It occurs sud- 
denly in the midst of health, or that degree of it which goes with 
modern civilization. Broncho-pneumonia is always a secondary pro- 
cess. It occurs in consequence of bronchitis, and as a result, in the 
rule, of infections in which bronchitis is a prominent symptom. Thus 
broncho-pneumonia occurs most frequently in the course of, or as a 
sequel to, measles, next pertussis, then diphtheria. It may occur 
also in connection with variola, typhoid fever, scarlet fever, rubella. 
The role of "cold" may not be ignored entirely in the production of 
the pneumonias. Lipari found that animals which had remained 
healthy after the endotracheal injection of pneumonia sputum were 



CATARRHAL PNEUMONIA. 523 

attacked with pneumonia immediately upon exposure to cold either 
before or after the injection. The cold weakened ciliary action and 
produced swelling of the mucosa, both processes which favored the 
growth of micro-organisms. 

Broncho-pneumonia is a disease of the extremes of life. It occurs 
most frequently in childhood, next in old age, and shows itself in 
adult life only in individuals who have been debilitated by previous 
disease. Ziemssen found that sixty-seven of ninety-eight cases, and 
Stephen that fifty -two of seventy-two cases, occurred in patients 
under three years of age. Jtirgensen ascribes it chiefly to the poi- 
soned atmosphere of ill- ventilated apartments. 

After tuberculosis and croupous pneumonia, it is the most com- 
mon cause of death in old age. Most of the cases of death from 
senile debility and "old age," and many of the cases of "heart fail- 
ure," are really due to the pneumonias. The disease process extends 








M 



*d 



Fig. 224.— Cellular pneumonia. Alveolar epithelium from the sputum : a, a', a", alveolar epi- 
thelium ; 6, myelin forms ; c, ciliated cells ; d, crystals of lime phosphate ; e, crystals of haema- 
toidin; /, white blood corpuscles; g, red blood corpuscles; h, squamous epithelium. 

to the air cells from the bronchial tubes by continuity of structure, or 
is inspired from upper into lower bronchi under the defective ciliary 
action of catarrhal inflammation and the muscular failures of pro- 
tracted disease or senescence. Thus decomposing foods from the 
mouth or throat, and unexpectorated mucus, are inhaled or inspired 
into the bronchial tubes and bronchioles, to produce infection at the 
seat of final arrest. The disease is therefore a diffuse process. It 
occurs throughout the substance of both lungs, but is observed 
chiefly in the lower lobes and along the spine, where gravity assists 
its deposit. 

Symptoms. — Broncho-pneumonia sets in, as a rule, insidiously. 
It is often impossible to draw the line between capillary bronchitis 
and catarrhal pneumonia. It is impossible to conceive of a marked 
case of capillary bronchitis without some catarrhal pneumonia, and 
it is safe to assume the existence of the pneumonic process in all 



524 CATARRHAL PNEUMONIA. 

cases of capillary bronchitis. The process is assumed to develop 
itself, because the bronchitis does not yield to treatment or to time. 
On the contrary, the signs of bronchitis which have previously ex- 
isted become more pronounced. The temperature runs higher. 
Fever, which may have been absent, or present in but light degree be- 
fore, now begins to assume prominence and persistence. The tem- 
perature runs up in the evening to 102° or 103°, sometimes to 104° or 
105°. The parents call attention to the heat of the skin, which is 
felt by the hand, or more especially by the face as applied to the 
chest in the act of auscultation. With this fever there is correspond- 
ing loss of strength, anorexia, and emaciation. The child is more 
and more peevish and fretful and restless at night as the fever be- 
comes more marked. If there is anything characteristic about the 
fever it is its irregularity. The temperature fluctuates as the dis- 
ease process changes in the lungs. The pulse is increased, and later 
on it becomes feeble and fluttering. Respirations are markedly 
increased from 20 to 30, 40, 50, 60, and more. They become corre- 
spondingly shallow and superficial. The older clinicians, in watch- 
ing the acts of respiration, said "the breath flies." The most re- 
markable peculiarity is, however, the disproportion between the 
pulse and the respiration. Instead of the relation of 2 : 9 or 1 : 4|, 
the ratio becomes 1 : 3, 1 : 2, or 2 : 3. This disturbance in the pulse- 
respiration ratio is a sign of great value in the recognition 
of the pneumonias. So a child with a pneumonia, or even with 
an extensive diffuse bronchitis, is not able to make a sustained 
effort with the respiratory organs. It cannot hold a long breath 
in crying. It must frequently release its hold from the nip- 
ple in nursing. Henoch thinks so much of this sign that he has a 
child put to the breast to make this observation. The physician, in 
auscultating, may be well content to await the inspiration that fol- 
lows a long cry, because the act itself excludes a pneumonia. Later 
on the picture of carbonic-acid poisoning supervenes. The sen- 
sorium becomes obtunded. There is cyanosis and coma; finally 
heart failure and death. 

The physical signs furnish information of but comparatively 
little value. As a rule percussion shows no dulness, except in the 
most advanced cases where numerous condensed lobules have coal- 
esced, or where in old people islets of condensation have extended to 
involve a large part of the lobe of the lung. Dulness in strips along 
the spine on both sides of the chest signifies catarrhal pneumonia. 
The auscultatory signs distinguish themselves by their number and 
abundance. They do not, however, especially distinguish the dis- 
ease. The signs which are present are those of an acute diffuse 
bronchitis. There is every variety of dry and moist sound. 



CATARRHAL PNEUMONIA. 525 

These sounds may be heard universally over the chest. They are 
usually heard in intensity in the back between the scapulae and spine. 

The diagnosis rests upon the existence of bronchitis, commonly 
in connection with measles, influenza, or some other acute affection ; 
later in life, in connection with senile bronchitis or tuberculosis. The 
disease develops with fever, increase in the frequency of respiration 
and of the pulse, disturbance of the pulse-respiration ratio. The 
course of the affection is irregular, subject to remissions and exacer- 
bations. It has no definite duration. The natural tendency of the 
disease is to extend. 

Catarrhal differs, therefore, from croupous pneumonia in the fact 
that croupous is a primary and catarrhal a secondary disease process. 
Catarrhal pneumonia attacks especially the extremes of life, infancy 
and old age; croupous pneumonia is more frequent in childhood, but 
is not infrequent in all periods of life. Croupous pneumonia begins 
suddenly, catarrhal pneumonia so insidiously as to make it impossi- 
ble to fix the time of its inception. There is seldom in catarrhal 
pneumonia pain, which is often acute in the beginning of croupous 
pneumonia. The brick-dust, glutinous sputum is peculiar to croup- 
ous, mucous and purulent sputum to catarrhal, pneumonia. Micro- 
scopic examination of the sputum reveals in croupous pneumonia 
the diplococcus, which is only exceptionally present in catarrhal 
pneumonias. Croupous pneumonia terminates, as a rule, in from five 
to nine days; catarrhal pneumonia has no definite duration, but ex- 
tends over weeks. 

Catarrhal pneumonia is separated from tuberculosis by the .local- 
ization of tuberculosis, more especially at the apices, by the action 
of tuberculin, and by the detection of the tubercle bacillus. 

The prognosis is always grave, even in infants where the future 
of croupous pneumonia is favorable. The bronchial tubes in infancy 
are so small as to be more or less completely occluded by a degree of 
inflammation which would have no effect upon adult tubes. In age 
the advantage in the size of the tubes is counterbalanced by the mus- 
cular failures of senescence. Taking cases as we find them, with 
what improvements in environment we are able to surround them, 
the mortality reaches forty per cent. The danger in catarrhal pneu- 
monia is double : first, on the part of the lungs, in that so much lung 
tissue is blocked off as to lead to death by suffocation, by carbonic- 
acid poisoning; and, secondly, catarrhal has the danger of croupous 
pneumonia of weakening the action of the heart, and, though the 
toxic effect of the disease is not so immediately pronounced, long 
duration of it finally breaks down the heart. The right ventricle 
becomes dilated and flabby; heart failure develops. 

Treatment has therefore the double object of stimulating the 



526 HYPOSTATIC PNEUMONIA. 

respiratory centres and sustaining the heart. Expectorants cannot 
accomplish much. Choice may be had of ipecac in the wine or 
syrup, or the compound syrup of squills, or apomorphia, which has 
the advantage that it may be given, in advanced cases, subcutane- 
ously. The older practitioners still administer antimony up to erne- 
sis— a practice that must not be pushed too far. Opiates are always 
dangerous. They merely mask the disease. "They are better substi- 
tuted by chloral, or may be admitted only in the form of Dover's 
powder. The best stimulant to the respiratory centre is the bath. 
A child should be put in a bath whenever the temperature reaches 
103° in the rectum, and the temperature of the water must be so 
regulated as to reduce this temperature two degrees within half an 
hour after the bath. The warm, the lukewarm, or the cool bath, 
with cold affusions upon the head, constitute the most powerful 
respiratory stimulus we possess. A child in the height of broncho- 
pneumonia should be put in the bath perhaps half a dozen times in 
the twenty-four hours. Antipyretics are of little value. A dose of 
phenacetin may secure sleep at night. It should be given alwaj^s 
with a little whiskey or wine. In the presence of pain hot applica- 
tions may be made to the chest. One may not speak derisively of 
the value of mustard plasters in the more protracted cases. The 
mustard may be made less irritating by admixture with flour or with 
the white of egg. In age the strength must be sustained with alco- 
hol. The more stimulating expectorants — senega, ammonia, cam- 
phor, benzoic acid — must substitute emetics. A drop or two of 
nitroglycerin two or three times a day will make a quick appeal to 
the heart, especially in the presence of sclerotic vessels. Digitalis 
sustains it best in the long run. Creosote and iodine are remedies of 
great value in more protracted cases. Cod-liver oil, good food, fresh 
air above all things, change of climate in more chronic cases, best 
meet the indications of treatment. Further details of treatment may 
be found in connection with Bronchitis. 

HYPOSTATIC PNEUMONIA. 

What knowledge we have regarding the process of hypostatic 
congestion we owe to Piorry, who showed that the congestion of the 
lungs which is found on the postero-inferior aspect in dead bodies 
was not a post-mortem phenomenon. He placed bodies after death 
on the side or on the stomach, and observed that the blood did not 
leave the region of its first deposit. On opening the body the hypo- 
stasis was still found on the posterior surface. Piorry had distin- 
guished the condition during life. Hypostatic congestion occurs in 
all cases of profound prostration or long debility. It is, therefore, 
seen most frequently in old people, whose lives are often curtailed by 



(EDEMA OF THE LUNGS. 527 

this process, but is observed also at any period of life as the result of 
prolonged decubitus, more especially of failures on the part of the 
heart. So victims of protracted tuberculosis, carcinoma, chronic 
infections, typhoid fever, rheumatism, paralyses, fractures of bone, 
etc., furnish the large contingent of cases. The condition occurs 
also not infrequently in the course of heart disease and catarrhal 
pneumonia, and displays itself by the signs of impeded circulation. 

Symptoms. — Piorry called attention to the fact that old people at 
the commencement of the disease begin to sleep with the mouth 
open, in order to secure the entrance of more air. A light cyanosis 
about the face often betrays the first hypostasis. Later the face is 
seen to grow more dusky and oedema of the lower extremities sets 
in. There is now dulness to percussion at the base of the lung, 
ascending upward from below. Respirations become more shallow. 

The treatment consists in the frequent change of posture — i.e., 
in turning the patient upon one side or the other, or upon the face, 
or especially to bring him to a semi- recumbent posture. Caffeine, 
the soda benzoate gr. iij. every two or three hours, camphor, nitro- 
glycerin, digitalis, best stimulate the heart. The patient must be 
taken out of bed as soon as possible. 

Embolic pneumonia is a complication of heart disease, and sep- 
tic pneumonia of pyaemia, 

(EDEMA OF THE LUNGS. 

(Edema {oidioo, to swell) of the lungs.— The passive escape of 
serum, containing red blood corpuscles, through paretic vessels into 
the interstitial tissue, alveoli, and bronchi; characterized by universal 
rales, cyanosis, dyspnoea, and asphyxia. The condition was for- 
merly considered a result of hydrsemia, a new which was disproved 
by Cohnheim and Lichtheim, who showed that oedema did not re- 
sult from the inundation of the blood with large quantities of the 
physiological salt solution (0.07 per cent). Welch developed oedema 
in some experiments in which he weakened the action of the left ven- 
tricle, leaving the right intact. Interference with the escape of blood 
from the left ventricle leads to the same result. The frequency with 
which the condition is found in connection with Bright's disease, 
tuberculosis, cancer, leukaemia, bespeaks the influence of disease of 
the vessels. CEdema of the lungs sometimes occurs suddenly in 
health, after copious cold drinks, hot baths, after paracentesis. A 
satisfactory explanation of these cases is wanting. The affection is 
bilateral, begins in the lower lobes, and gradually ascends. 

Symptoms. — Sometimes the condition develops insidiously, some- 
times suddenly. The symptoms result from defective aeration of the 




528 ATELECTASIS. 

blood, and are the same whatever the seat of the occlusion. (Edema 
of the lungs is usually announced by interference with respiration, 
by rapid respiration, appeal to all the auxiliary muscles, increas- 
ing cyanosis, sense of suffocation, and anxiety. The face Wears 
the look of desperation. The sputum is thin, foamy, tinged ivith 

blood. In disease of the kidneys it contains 
urea. Inspection shows the limited excur- 
sion of the chest. Percussion gives dulness 
below, increased resonance, even tympani- 
tes, above the infusion. Auscultation dis- 
closes universal mucous and submucous 
rales, which drown all other sounds, which 
may be felt in palpation, may be heard by 
fig, 225.-(Edema puimo- the patient himself, and often by others in 

num. Desquamated epithelium ., .... 

enclosing particles of coal. tne Vicinity. 

x 3oo. The prognosis is always grave, but 

depends upon the underlying cause. Where 
the disease is not irremediable, and the heart can be forced to extra 
work, the patient may recover. Death is by heart failure and car- 
bonic-acid poisoning. 

The treatment consists wholly in appeal to the heart by caffeine, 
the soda benzoate, which may be administered internally or injected 
subcutaneously in doses of two or three grains every hour or two ; 
digitalis infusion, dessert- to tablespoonf ul every two or three hours ; 
alcohol. The hot bath, hot pack, may, by derivation to the surface, 
unload the congested vessels in the lungs. For the same purpose a 
venesection is justifiable in florid cases. 

ATELECTASIS. 

Atelectasis (arsXr/S, ineffectual, enraGiS, expansion) ; hepatiza- 
tion ; splenization. — A collapse of the lung, congenital or acquired, 
which results from defective expansion, or from occlusion of bronchi, 
with reabsorption of gases, first of oxygen, then of carbonic acid, last 
of nitrogen. 

Etiology. — Congenital atelectasis results from lack of expansion, 
on account of injury to, or death of, the respiratory centre, as in 
compression of the umbilical cord, protracted labor, premature 
birth, etc. 

Acquired atelectasis occurs in consequence chiefly of occlusion of 
bronchi with mucus, false membrane (croup), meconium, blood, 
foreign bodies, or of processes which interfere with expansion, effu- 
sions into the pleura, pneumothorax, deformities of the vertebrae 
(tuberculosis and rickets), ascites, protracted tympanites, etc. The 
condition may be limited, localized, in individual bronchi ; or exten- 



DROWNING. 529 

sive, involving numerous lobules, lobes, or the greater part of the 
lungs. 

Symptoms. — Atelectasis limited to a lobule or a few lobules may 
show no signs. Unaffected parts of the lungs supply the defect. 
Compensation may be excessive and result in emphysema. Where 
one-sixth to one-eighth of a lung is involved the symptoms are dis- 
tinct. The new-born child is born asphytic ; the surface is blue 
and cold. The child may be born dead or dying, so that efforts at 
artificial respiration, particularly swinging by the feet (Schultze's 
method), must be resorted to ; or the respiration is feeble, the chest 
fails to expand, the intercostal muscles sink in as in inspiratory 
dyspnoea; there is no cry, or the voice is feeble and whimpering. 
The patient slowly recovers, or death occurs from heart failure, 
thrombus of a brain sinus. Inspection reveals immobility of the 
chest, with collapse of the intercostal spaces. There is lessened re- 
sonance to percussion, enfeebled vesicular rale, diminished fremitus, 
and, with extensive consolidation, bronchial respiration. Capillary 
bronchitis and bronchial pneumonia easily supervene. 

Diagnosis. — The condition is to be separated from hemorrhagic 
infarction, which shows bloody sputum, pain, and pleuritic frictions. 
Croupous pneumonia distinguishes itself by fever, crepitus, and short 
duration ; pleurisy by pain and friction sound, change of the line of 
dulness with change of position, and absence of retraction of the 
chest on inspiration. Slight atelectases may be suspected on account 
of the superficial respiration, reduction of temperature, changes in 
circulation, which cannot be accounted for in other ways. 

The prognosis varies. Asphytic children may be recovered by 
artificial respiration, baths, douches of cold water, faradization. The 
outlook is worse with premature births. In the acquired form the 
prognosis depends upon the cause. Associate pneumonia or tuber- 
culosis, stenosis of the pulmonary valves, permanence of the fora- 
men ovale, make the prognosis grave. 

Treatment consists in stimulation of the respiratory centre by the 
methods referred to. The asphytic child is to be kept warm, and, 
with established respiration, laid upon its right side. Stimulants, a 
few drops of brandy in hot water, may be administered from time to 
time. In the acquired cases the treatment is the same as that of 
broncho-pneumonia. 

DROWNING. 

Drowning is the asphyxia produced by submersion in fluid media. 

Death by drowning occurs by accident, suicide, and homicide. In 

the reign of Charles V. drowning was inflicted as a death penalty 

for child murder ; and as late as the end of the seventeenth century, 

34 



530 DROWNING. 

in certain countries — Styria and Tyrol — the body of the suicide which 
was refused consecrated burial was put on a boat and sent adrift. 

Accidental drowning is not so common since the rail has so 
largely substituted the river. Nevertheless it occurs not infrequently 
among pleasure seekers, yachting parties, etc. Boys are drowned 
more frequently than girls. Girls remain at home and are more 
frequently burned. Drowning sometimes occurs in the bath tub in 
sudden syncope, alcoholism, epilepsy, apoplexy, etc. 

Homicide by drowning is rare. In a thousand cases collected by 
Belohradsky homicide by drowning occurred in but twenty-three* 
and then, as a rule, under peculiar circumstances. Thus, Henle re- 
corded a case where a laborer, driven to desperation through want, 
drowned his four children ; Casper-Liman, a lithographer who 
drowned his four children ; Maschke, an insane woman who pushed 
her two daughters into the water. But drowning of the new-born 
is frequent. Nearly one-third of the violent deaths of the new born 
occur in this way. The new-born may have drowned in the liquor 
amnii by premature respiration (breech presentation) during as well 
as after birth. 

Suicide numbers the most victims, and chiefly in the female sex. 
Ever since Sappho plunged from the cliff, unhappy women have 
found relief in death by drowning. But statistics differ. Thus sui- 
cide by drowning occurs in Vienna in but 5 per cent of cases, in Paris 
in 21.5, in Italy in 38 per cent. The little piece of the Seine which 
runs through Paris numbers more victims than all the rest of the 
river, or than any other part of a river of the same length. Drown- 
ing is naturally more frequent where opportunity is more abundant. 
It is rare in inland cities away from rivers, lakes, reservoirs, etc. 
Locus aggravat crimen. But a very small amount of water is 
necessary to drown. Devergie relates a case where a mother took 
her four children to a canal in which the water was but two feet 
deep, prayed with them, and plunged with them into the water. 
The mother and youngest child were rescued alive. Smith reports 
the case of a woman who cut a hole in the ice and held her head in 
it until she drowned. Drunkards and epileptics have drowned in 
water insufficient to cover the entire head. If the face can be held 
in water for half a minute, or until asphyxia occurs, the individual 
loses the power to rescue himself and his fate passes out of his own 
hands. 

The specific gravity of the body is greater than that of water, 
hence there is a natural tendency to sink; but the tendency is not 
great, and but slight effort is required to keep the face above water. 
The greatest weight is in that part of the body out of the water and 
unsupported by water ; hence struggle in the effort to escape, as in 



DROWNING. 531 

throwing the hands out of the water, increases the weight of the 
body. Fat is lighter than water, hence fat people, women, and chil- 
dren float more easily. The head, from its weight, sinks most 
readily. The body generally rises to the surface during drowning 
until the air from the lungs escapes in bubbles, and always after it 
in the course of two or three days, unless restrained by weight or 
entanglement. The gases of decomposition suffice to lift the body to 
the surface. 

The immediate sensations of drowning are really agonizing. They 
attend the struggle for air, which is always powerful and painful. 
But the struggle is of very short duration, and dyspnoea is quickly 
succeeded by loss of consciousness and convulsions. An indescrib- 
able delirium, with ringing of the ears, is quickly followed by 
loss of consciousness, and the period immediately preceding the 
loss is attended with sensations at times pleasurable. Marryatt said 
the feeling was not one of pain, but "of sinking into sleep in the long, 
soft grass of a cool meadow." Sometimes drowning is entirely un- 
attended with struggle, as after injury to the head, in epilepsy, apo- 
plexy, syncope, alcoholism, etc., when the body sinks at once like 
a mass of lead, to rise no more. 

The duration of submersion necessary to produce death varies. 
Children, especially the new-born, withstand asphyxia longer than 
adults, in whom two minutes usually suffice to take life. Johnson, 
the champion swimmer of England, could remain under water three 
minutes and ten seconds. Dogs die in four minutes. 

Recovery from asphyxia by drowning is more difficult than from 
other cause. Water exercises an injurious effect upon the lungs. A 
dog with his windpipe plugged to prevent the ingress of water may 
be recovered from asphyxia after four minutes' submersion, while a 
dog not so protected succumbs. 

The various signs of death by drowning are, for the most part, 
deceptive. The blood is usually dark and thin ; the internal organs 
often, but not always, hyperemia The skin is covered with goose 
flesh from contraction of the cutaneous muscular tissue. Mertzdorf 
called attention to the extreme cold of the drowned body. This is 
especially observable in bodies drowned in fresh water and after par- 
tial removal of the water. The coldness is due to rapid evaporation 
from the saturated epidermis. The epidermis itself shows signs of 
maceration, most marked where thickest, as in the palms of the 
hands and soles of the feet, and most marked on the hands of the 
laborer. The degree of maceration is an index also of the duration 
of submersion. Signs of maceration show themselves in the pulps 
of the fingers and eminences of the hand in two to three hours, in the 
palms which assume a sodden appearance in two to three days. 



532 DROWNING. 

The whole hand becomes chalk- white in five to six days. Decompo- 
sition shows itself from above downward, and depends in degree and 
time of occurrence upon the exposure, season, temperature, fluid, etc. 
Thus it occurs earlier in summer and in sewage. It becomes often 
a nice question in forensic medicine to determine whether a body 
was drowned, or was thrown into the water after death from other 
cause. The question depends largely upon the evidence of breathing 
in water. In the convulsions and terminal struggles of drowning 
water may be swallowed and its presence recognized in the stomach. 
Unfortunately the stomach generally contains fluid. The discov- 
ery of fluid of particular character, liquor amnii, sewage, etc., fur- 
nishes evidence of more value. Fluid, or more particularly fine 
foam, in the lungs — i. e. , issuing from the bronchial tubes and trachea 
like foam from a beer bottle — may likewise indicate aspiration of 




Fig. 226.— Marshall Hairs method. 

"water. Here too, however, is room for doubt, as the same condition 
may be encountered in other states, as in oedema of the lungs, etc. 
Of most value is the sign furnished by Hofmann — the detection of 
fluid in the middle ear. Fluids, even chemical test fluids, as the 
ferrocyanide of potassium, do not penetrate to the middle ear in 
bodies submerged after death. The discovery of fluid in the cavity 
of the drum is therefore evidence of great value, especially in the 
case of the new-born, in whom the observation is easily made by cut- 
ting out the roof of the drum with a pair of scissors after removal of 
the brain in this region. Any fluid present is withdrawn by a pi- 
pette and examined under the microscope. The operation is more 
difficult in the adult and requires the use of the chisel. Penetration 
to the tympanum does not occur in cases where death takes place 
without struggle. The finding of fluid in the cavity of the drum is 
therefore not universal in cases of drowning. 



DROWNING. 



533 



Although death usually results from submersion of a few minutes, 
cases have been rescued after much longer periods. Sometimes in 
these cases the submersion has not been complete or the body has 
come to the surface repeatedly and some air has been inhaled. New- 
born children have been rescued after submersion for ten minutes. 
A most remarkable case is reported in the Annales cV Hygiene Pub- 
lique, vol. xliv., page 306, of the rescue of a boy aged fifteen after sub- 




Fig. 227.— Sylvester's method. 

mersion for nearly an hour. Efforts at resuscitation should not be 
abandoned after submersion short of one hour. In all cases attempts 
should be made to empty the air passages of water. The older methods 
of suspension by the feet or rolling the body over a barrel are bad. The 
body should simply be inclined downward, as on the bank of a 
stream or in a boat, the chest raised with the clothing, and com- 
pression exercised from below upward by the hand over the stomach. 
The diaphragm may be thus forced upward and the water extruded 




Fig. 228.— Sylvester's method. 

through the open mouth. Wet clothing should be immediately re- 
moved, the body quickly dried and warmed with hot- water bottles. 
Fires may be made in the vicinity and stones heated as substitutes. 
Remarkable results have been reported from the application of hot 
water alone. The clothes saturated with hot water, 110° to 140° F., 
and applied about the surface, stimulate the centres of respiration 
through the skin, as does exposure of the skin in the first acts of 
breathing in the new-born. 



534 EMBOLISM OF THE LUNGS. 

Various methods of rescue have been proposed. They depend 
entirely upon securing artificial respiration. 

The first method devised was that of Marshall Hall. It con- 
sisted in turning the body over on the side to secure expiration and 
turning it back to secure inspiration. 

The method of Sylvester was an improvement. Sylvester's 
method consists in raising the arms above the body by the side of 
the head to secure expansion of the chest and inspiration, and then 
depressing them again by the side of the body, with some compres- 
sion, [to secure expiration. Satterthwaite suggests also the with- 
drawal of the tongue to keep the larynx open. 

Howard's method is a further improvement. The operator be- 
strides the body, places his hands upon the front and sides of the 
chest, with the thumbs by the side of the sternum, throws his 




Fig. 229.— Howard's method (Satterthwaite). 

weight forward upon the body, making at the same time lateral 
compression, while he counts one, two, three, or up to five ; and 
then, with a final push, in which the hands are assisted with the 
knees, throws himself back, that the chest may recover from the 
compression with a spring. These various acts of compression are 
made first slowly, and gradually more rapidly until some signs of life 
appear. 

Bad signs are drooping, half -closed eyes, rigid, incurved fingers, 
extreme and persistent coldness of the surface. The first signs of 
respiration are twitching of the muscles of the face, slight flushing, 
and gasping respiration. Bodies submerged for but a short time 
soon begin to gasp and speedily recover. 

EMBOLISM OF THE LUNGS. 

Embolism of the lungs ; hemorrhagic infarction. — Infarction 
results from the occlusion of pulmonary arteries by thrombus or em- 



EMBOLISM OF THE LUNGS. 535 

bolus. It may result only when the circulation of neighboring capil- 
laries is insufficient to counteract the stasis, which condition may 
occur in connection with affections of the lung or insufficiency or 
stenosis of the mitral valve. Blood vessels may be blocked also by 
accumulation of white blood corpuscles in leukaemia. A simple 
mechanical plug produces the infarction. Infected matter breaks 
down the tissue in its vicinity, to constitute the metastatic abscess. 
Infarction is usually peripheral, cone-shaped, with the base at the 
pleura. The tissue is brown or black, firm, and distinctly separated 
from the sound tissue. The pleura maintains its lustre at first, but 
later becomes cloudy and covered with fibrin. Emboli usually 
come from the systemic veins, especially from the iliac and its 
branches, from the prostate and uterus, sometimes from lesions of 
valves in the right heart. The process is favored by retardation of 
circulation or heart disease. On account of paresis of the vessels 
from lack of nutrition the vessels become permeable, and blood 
fills the alveoli and bronchioles of the whole domain supplied by the 
occluded vessel — that is, the stasis leads to diapedesis. Conditions 
which produce sudden changes in the circulation may dislodge par- 
tially developed thrombi. Thus the accident has occurred after 
violent effort, the application or release of pressure, as chest corsets, 
bandages of varicose veins, laparotomy, emptying of cysts, etc. 
Metastatic abscess is found in connection with pyaemia, especially 
puerperal fever, ulcerative endocarditis, gangrene, furunculosis, etc. 
Symptoms. — A small infarction may show no signs. Occlusion 
of a large branch of the pulmonary artery usually takes life at once. 
If the occlusion is not complete or the branch not so large, severe 
symptoms ensue — extreme dijspnoea, syncope, convulsions, or 
coma. Stress is to be laid upon the loss of consciousness, espe- 
cially if associated with convulsions or preceded by dyspnoea or 
haemoptysis. The dyspnoea is the most distressing sign ; it becomes 
extreme, and is attended with the* efforts and anxiety of despair ; 
the heart's action becomes feeble, the pulse thready, the surface 
clammy with a cold sweat. The pleurisy gives rise to severe pain ; 
there is harassing cough and expectoration of dark, gelatinous 3 
bloody mucus. The sputum contains also peculiar large lymph 
cells, resembling alveolar cells, embodying blood corpuscles, some- 
times as many as five or even more. These giant cells transform the 
blood corpuscles into pigment matter. They are seen especially in 
cases of heart disease, and are known as the cells of heart failure. 
Metastatic abscesses are accompanied by chills and the fever that 
belongs to pyaemia (puerperal, etc.). Physical examination reveals, 
as a rule, moist rales, dulness to percussion, increased fremitus 
and resonance, bronchial respiration. Partial occlusion of the 



536 



ABSCESS OF THE LUNGS. 



pulmonary artery develops a systolic murmur, with fremissement 
at the second left costal cartilage. 

The diagnosis rests upon the sudden supervention of loss of con- 
sciousness, convulsions, dyspnoea, pain in the side, cough, bloody 
sputum, with the signs revealed by physical examination, in connec- 
tion with the condition which might develop a thrombus or embolus. 

The prognosis is always grave, but recovery is possible with the 
dissolution of the thrombus. Metastatic abscesses give the ominous 
outlook of pysemia, but recovery is not impossible in these cases. 

Treatment. — Inasmuch as the detachment or dissolution of the 
thrombus or embolus by artificial means is out of the question, 
treatment resolves itself into such disposition of the body as will 
favor the natural occurrence of these processes. Prophylaxis is of 
most importance. To discover the concealed disease, especially in 
connection with maladies of the uterus and prostate gland ; to pre- 
vent, so far as may be, the formation of thrombi by antiseptic 
treatment of infectious disease ; to secure the greatest possible rest, 
with immobilization of affected extremities, varicose veins, etc., ex- 
haust the resources of therapy. Dyspnoea and pain demand the use 
of morphia subcutaneously. 



ABSCESS OF THE LUNGS. 

Abscess of the lungs is not an independent malady. Abscess de- 
velops in connection with tuberculosis 
as a vomica full of pus, detritus, micro- 
organisms, mould fungi, etc., or from 
the coalescence of smaller metastatic 
abscesses in the course of pyaemia. 
Abscess may result from pneumonia, 
especially catarrhal pneumonia, mixed 
infection, or trauma, including lesions 
of bronchi (foreign bodies). 

The symptoms are those of the ori- 
ginating malady. The sputum is pur- 
ulent, generally greenish, sometimes 
- brownish as tinged with blood. It is 
made up chiefly of pus corpuscles with 
alveolar epithelium, elastic fibres and 
masses of lung tissue, detritus, crys- 
tals of margarin, cholesterin, hsemato- 
idin with blood pigment matter, phos- 
fig. 230.— Mould fungi from sputum phates, and various mould fungi and 
of abscess of lungs. bacteria. The diagnosis may be estab- 

lished, with the aid of physical signs — dulness to percussion, in con- 



GANGRENE OF THE LUNGS. 



537 



nection with fever, usually remittent — by aspiration, a perfectly safe 
procedure with a perfectly clean instrument. When the diagnosis is 
established the abscess may be discharged by aspiration or incision. 
As most cases depend upon tuberculosis, the evacuation of the abscess 
does not cure the disease*; in fact, an operation sometimes quickens 
its course. Where address is made at the same time to the cause of 
the disease by creosote, tuberculin, etc., the operation is justifiable. 
Abscesses from other cause (pneumonia, pyaemia) sometimes dis- 
charge themselves into the bronchi or pleural sac. Operation in all 
these cases may rescue the patient from the dangers of discharge into 




Fig. 231.— Sputum from abscess of lungs, showing elastic tissue, fat crystals, phosphates, epi- 
thelium, pigment matter, pus cells, and bacteria. • 

the pleura, pericardium, peritoneum, etc. , as well as from the remoter 
evils of amyloid change and marasmus. 



GANGRENE OF THE LUNGS. 

Gangrene of the lungs is a rare condition. Primary gangrene, in 
consequence of trauma, with penetration from without of the organ- 
isms of decomposition, is very rare. The disease results rather more 
frequently *from croupous and catarrhal pneumonia, infarction, 
neoplasms, cancer, echinococcus, actinomyces, abscess, and most in- 
frequently from tuberculosis. Decomposing matter may be aspirated 
from the bronchial tubes into the air cells, especially in cases of sub- 



538 GANGRENE OF THE LUNGS. 

jects suffering with coma or paralysis, alcoholism, old age, etc. The 
condition is twice as frequent in males, and occurs especially be- 
tween the ages of twenty and fifty, the period of greatest exposure, 
and among the poorer classes. 

Symptoms. — The gangrene may be circumscribed or diffuse, 
central or peripheral ; it may reach and destroy the pleura and 
lead to pyopneumothorax. The disease is usually announced with 
fever from the absorption of putrid matter. The fever is attended 
with chills and prof use sweats, as in the case of pyaemia. The pa- 
tient falls into a typhoid state, with delirium and coma. Pain in 
the side indicates a developing pleurisy. The cough is usually dry, 
continuous, and harassing. The characteristic sign is the expec- 
toration of putrid sputum. The sputum is generally abundant, is 
often mixed with blood whose corpuscles are usually disintegrated. 
The odor is excessively fetid and penetrating ; it fills the room 
or the large ward of a hospital, and may be perceived in adjoining 
rooms ; it contaminates everything in contact with the patient. On 
standing it settles into three layers — an upper, frothy, greenish, 
purulent ; a middle, greenish opaque ; a lower, purulent, greasy, 
greenish mass, in which are found the characteristic grayish par- 
ticles, plugs of the small bronchial tubes (the so-called Dittrich 
plugs), with detritus, fat globules, pus cells, and bacteria, mould 
fungi (leptothrix). The disease is distinguished from putrid bron- 
chitis by the presence of particles of disintegrated lung tissue, 
grayish-black matter of irregular surface, containing little or no 
elastic tissue, which is supposed to be destroyed by a ferment some- 
thing like trypsin. Sputum in general is sometimes so tough as to 
be teased thin with difficulty. In such case it should be diluted on 
the object glass with a solution of common salt 0.75 per cent, not 
with pure water. The following two solutions are used in the study 
of sputum : (1) dilute acetic acid 1 : 100 distilled water ; (2) soda 
lye 3 : 100 distilled water. The one-per-cent solution best clears up 
fibrin and displays nuclei ; the three-per-cent solution destroys the 
protoplasm, gradually also the nuclei, but distinctly displays elastic 
tissue and micro-organisms (Graber). 

The decubitus in gangrene is usually on the affected side ; re- 
cumbent when the disease is situated in the upper lobes, semi-re- 
cumbent when in the lower lobes. 

Circumscribed gangrene reveals no signs on physical examina- 
tion. More extensive change shows the symptoms of consolidation 
— dulness to percussion, bronchial or amphoric respiration, 
cracked-pot sound, etc. Pleurisy, pneumothorax, and pyopneumo- 
thorax reveal themselves with their distinctive signs. Pyaemia 
with metastatic abscesses may ensue. The course is chronic. The 






CARCINOMA, SARCOMA, ECHINOCOCCUS OF THE LUNGS. 539 

disease lasts, with remissions and exacerbations, from several months 
to several years. 

The diagnosis depends chiefly upon the fetid sputum. Fetor 
from the mouth or nose is excluded by absence of disease of these 
organs ; putrid bronchitis, by the presence of lung tissue. Simple 
abscess shows purulent sputum without offensive odor, containing 
abundant elastic fibres. 

The prognosis is always grave, but depends upon the extent of 
the disease and the strength of the patient. Recovery is announced 
by the substitution of purulent sputum without offensive odor. Pa- 
tients usually succumb to marasmus. 

Treatment. — The condition may be prevented often by attention 
to the mouth in cases of paralysis, protracted infections, etc. The 
mouth is to be kept clean with borax, myrrh, thymol. Creolin, one 
per cent, makes a good mouth wash. The same attention is to be 
paid to the nose, into which- boric- acid ointment gr. xv.- 3 i. unguen- 
ti petrolati may be insufflated. Traube recommended the acetate 
of lead, half a grain every two hours, especially in relief of haemor- 
rhage. The sputum should always be received in water strongly 
impregnated with carbolic acid or lysol. The best treatment con- 
sists in the administration of stimulants and expectorants, with the 
use of disinfectants, as already fully discussed in connection with 
putrid bronchitis. As expectorants, the best remedies are senega, 
benzoic acid, apomorphia; and as disinfectants, turpentine, thymol, 
pyridin. and myrtol. A good preparation of creosote in capsule, or 
with the tincture of mix vomica equal parts, administered with 
whiskey and water in equal parts, five drops of the creosote mixture 
to a tablespoonful or two of the whiskey and Avater, constitutes a 
fine expectorant, stimulant, and disinfectant, as well as a good sto- 
machic tonic. 

SYPHILIS OF THE LUNGS. 

Syphilis of the lungs is rare and is usually congenital. It pre- 
sents itself in the form of gummatous deposits of the size of a pea to 
a hazelnut, which subsequently undergo softening. A more common 
form, especially in the new-born, is the syphilitic pneumonia, which 
consists in a hyperplasia of the connective tissue, and leads to exu- 
beration and desquamation of the epithelium. Nearly all the cases 
of so-called syphilis of the lungs in adults are cases of tuberculosis 
in syphilitic subjects. 

CARCINOMA, SARCOMA, ECHINOCOCCUS OF THE LUNGS. 

Carcinoma of the lungs is secondary, and depends upon metas- 
tases conveyed from some distant seat, usually by the lymph, or 



540 PNEUMONOCONIOSIS. 

results from extension by contiguity, as from the oesophagus, vertebra, 
mediastinum, pleura, etc. The right lung is affected more fre- 
quently than the left, the upper than the lower lobes. Cancer of the 
lung is more common in men, and occurs usually at an age earlier 
than cancer elsewhere. Primary cancer is very rare. It develops 
in these cases from the epithelium of the bronchial tubes. It has 
been most frequently observed in the Schneeberg cobalt mines, where 
it is attributed to the inhalation of arsenic in association with the 
cobalt, and where it is said to cause three-fourths of all deaths. It 
is usually medullary, and m metastatic form is commonly found in 
association with metastases elsewhere. 

The signs of cancer of the lungs are for a time those of bronchi- 
tis. Sooner or later the sputum begins to be tinged with blood, not 
continuously but irregularly, and occasionally it assumes a peculiar 
raspberry- jelly appearance which is very characteristic. Eusty spu- 
tum occurs also, and sometimes a sharp haemorrhage. The diagnosis 
can be definitely declared, however, only by the discovery of cancer 
tissue in masses accidentally dislodged. 

Sarcoma of the lungs is even more rare than carcinoma. It has 
been observed in connection with lympho- sarcoma of the cervical 
glands, more frequently as a metastatic deposit in connection with 
osteo-sarcoma. 

Echinococcus is usually found in connection with echinococcus 
of the liver, and may be suspected when cough, pain, dyspnoea, with 
the physical signs of consolidation, are found in cases of echinococ- 
cus of the liver. The diagnosis can be absolutely established only 
with the recognition of scolices, hooklets, etc., in the sputum. 

The treatment of these conditions is wholly symptomatic or sur- 



gical. 



PNEUMONOCONIOSIS. 



Pneumonoconiosis (nvEvjAoov, lung, uovia, dust), the disease 
produced by inhalation of dusts in various avocations, used as a gen- 
eral term to include anthracosis, inhalation of coal dust; chalicosis, 
inhalation of lime and stone dust; siderosis, inhalation of iron dust, 
etc. 

History. — The character of the coloring matter found in and on 
the surface of the lungs was long a matter of dispute. Pearson and 
Laennec expressed the suspicion that it was coal dust. Virchow 
considered it an organic pigment of internal formation. Traube 
(1860) first demonstrated the actual presence of coal dust in a miner's 
lungs, and Zenker showed the difference between this dust and or- 
ganic pigment. Hirt, in his thorough studies, reached the conclusion 
that vegetable dust and mixed dust are much more intense irritants 



PNEUMONOCONIOSIS. 541 

to the mucous membrane of the respiratory tract than metallic, mine- 
ral, or animal dust. 

Considerable accumulation of dust may occur in the lungs with- 
out damage. The body is protected against exposure by outside 
guards — hairs, moist surfaces which retain deposits, cilise — by cough, 
etc. A sound mucous membrane with perfect ciliary action gradu- 
ally extrudes foreign particles. It is only when the quantity is in ex- 
cess or is directly injurious, as in the case of gases, micro-organisms, 
etc., or, more especially, when the mucous membrane is affected with 
catarrh or other process which weakens ciliary action, that dust in- 
halations produce disease. Hence the mass of individuals exposed 
to the inhalation of dust escape disease. Disease produced by micro- 
organisms do not enter into consideration here. Occasional cases 
of disease from coal and stone dust occur among miners, chimney 
sweeps, foundrymen, stone and brick masons, plasterers, mill work- 
ers, glass and china factors, ivory grinders, lithographers; cases from 
inhalation of metallic dust, among the various iron smiths, copper 
smiths, etc.; cases from the inhalation of vegetable dust, among 
grain shovellers, cotton spinners, wood workers, millers, cigar mak- 
ers, etc. 

Symptoms. — The irritation produced by the inhalation of these 
dusts causes in certain cases at first acute and subsequently chronic 
bronchitis, which does not differ in any way, save by the presence of 
the various dusts, from bronchitis from other cause. Protracted bron- 
chitis results in bronchiectasis, emphysema, hypertrophy and dila- 
tation of the right ventricle, as in cases from other cause. The pene- 
tration of the bronchial tubes by foreign particles excites inflam- 
mation in the interstitial tissue, which results in the formation of 
small, hard nodules, constituting interstitial pneumonia. This affec- 
tion is, however, rather suspected than recognized, on account of the 
obstinacy of symptoms. Inhalation of coal dust rather protects 
against than invites tuberculosis; vegetable dust favors the develop- 
ment of the disease. 

The diagnosis is the recognition of bronchitis, more especially 
chronic bronchitis, which disappears with removal to a purer at- 
mosphere, but recurs with renewed exposure. The various dusts dis- 
appear from the bronchial tubes, as a rule, in the course of ten to 
twelve days' stay in a purer atmosphere. Persistence in the sputum 
after this period indicates organic change in the bronchial mucous 
membrane. The nature of the dust may be known from the charac- 
ter of the avocation, or may be recognized in the sputum under the 
microscope. The addition of the ferrocyanide of potash to sputum 
boiled with hydrochloric acid, demonstrates the presence of iron by 
the formation of Prussian blue. 



542 PLEURISY. 

The prognosis is favorable under a proper hygiene. Factors in 
dusty atmospheres should be allowed hours of exercise in the fresh 
air. Better ventilation may be secured in the workrooms them- 
selves. 

The treatment does not differ from that of bronchitis from other 
cause. 

PLEURISY. 

Pleurisy (-n:\evpa, the side). — Infection of the pleura by the diplo- 
coccus, streptococcus, tubercle bacillus, etc. 

History. — Paracentesis was performed even before the days of 
Hippocrates. Euryphon of Cnidos is said to have saved the life of 
Cinesias by opening the chest with the actual cautery. Hippocrates 
was thoroughly familiar with the operation. He even advised the 
very latest suggestion in therapy, to close the wound, after part of 
the pus was discharged, with a roll of linen to which a thread was 
attached, and to let off some of the matter every day. Hippocrates 
made use also of a zinc drainage tube. " If the pus is clean, white, 
or tinged with blood, the patient will recover. If it is thick, green, 
or ichorous, he will die. " 

Pleurisy was not separated from pneumonia in ancient times. 
There is reason for this failure in the fact that the diseases now 
are so often found associated. Sydenham, Morgagni, and Haller, 
with Boerhave and Van Swieten, all believed that the lungs were 
affected in this disease as much as the pleura itself. Pinel first 
gave pleurisy its distinct place, and Laennec, with the discovery of 
the friction sound, furnished the ability to distinguish the disease in 
life. The turning point in the treatment of pleurisy was reached 
in the discovery of the aspirator by Bowditch, of Boston, in 1852. 
The fact that pleurisy is never, strictly speaking, a primary mal- 
ady, but occurs as the result of an infection which shows itself in 
some other organ, or is, at least, due to micro-organisms which pro- 
duce diseases of other organs, is a matter of recent acquisition. 

Etiology. — Pleurisy is looked upon in our day as an expression 
or localization of one of the infections. The pleura is the serous 
membrane most frequently invaded in the course of infectious dis- 
eases. The cause of pleurisy was formerly ascribed to trauma or 
taking cold; a penetrating wound from without, as a stab, or from 
within, as a rupture from a broken rib, or invasion from caries of the 
vertebrae, foreign body in the oesophagus, aneurism, etc. Any in- 
flammation as the result of disease in a contiguous structure will 
produce inflammation of the pleura, but not that distinct form of 
disease which is set apart as a simple or distinct pleurisy. The diffi- 
culty of discovering the cause of pleurisy, the cause of inflammation 
in a structure so deep-seated and apparently secluded from all avenue 



PLEURISY. 543 

of ingress, led pathologists to adopt the view that pleurisy was an 
expression of tuberculosis . This view was fortified by the fact that 
the diseases were so often found associated, and that the subjects of 
pleurisy become not infrequently subsequently victims of tubercu- 
losis. Further study has shown, however, that this cause applies 
only to the minority of cases, that most cases of pleurisy depend upon 
the invasion of other micro-organisms than the bacillus tuberculosis. 
Bacteriological studies of recent years, as by Netter and Lev}^, reveal 
the fact that most cases of pleurisy are due to the micro-organisms 
which produce pneumonia — the diplococcus of Frankel and the 
pneumococcus of Friedlander. better shows that all forms of pleu- 
risy are of microbic origin, but that the microbes producing them are 
of many different kinds. In one hundred and nine examinations of 
purulent pleurisy he found, in different cases, pneumococci, pyogenic 
streptococci, staphylococci, the bacillus tuberculosis, Friedlanders 
encapsulated bacillus, the pseudo-typhoid 
bacillus, Micrococcus tetragenus, spirilla, 
filaments of leptrothrix, and saprogenic bac- 
teria. 

The cases of simple serous effusion dis- 
tinguish themselves often by negative evi- 
dence. These cases are called rheumatic 
and are attributed to the cause of rheuma- 
tism (Fiedler). In some of these cases, 
however, the diplococcus has been discov- „ „ Ma ,_. 

. . Fig. 232.— Micrococcus pneumo- 

ered as the evident cause of the disease, niae crouposa?, showiDg capsuier 
Cases secondary to Bright's disease are be- *«>" exudate in pieund cavity of 

. . . inoculated rabbit (Sternberg, 

heved to owe their origin to chemical pro- after saivioio. 
ducts, toxines, rather than to the direct 

presence of a micro-organism itself. Attempt has been made to 
declare the future of a case, whether it will remain serous or be- 
come purulent, by the character of the micro-organism encountered 
in fluid withdrawn for examination. Decisive results have not yet 
been reached. It is certain that the diplococcus of Frankel is often 
found in cases which remain serous, and that the exclusive presence 
of this organism justifies a favorable prognosis. The pyogenic micro- 
organisms do not necessarily determine suppuration. 

The role of exposure to cold in pleurisy is the same as that of the 
other infections. It may awaken a dormant process or localize an 
existing infection. As a rule "taking cold" expresses merely the 
onset and outbreak of a disease. In pyaemic processes the pleura is 
involved with the other serosse; so pleurisy may occur in the course 
of puerperal fever, scarlatina, dysentery, rheumatism, etc., as a sec-, 
ondary process, sometimes as a terminal link in the chain of disease. 




544 



PLEURISY. 



The pleurisy which apparently develops first is found to be pro- 
duced, as stated, most frequently by the diplococcus or other micro- 
organisms of pneumonia, so that pleurisy and pneumonia are asso- 
ciated as a rule. The pain in pneumonia belongs to pleurisy. It is 
a question rather which disease process predominates. It is possible 
to have a central pneumonia without a pleurisy, as it is possible to 
have a pleurisy without pneumonia. The rule is that pneumonia 
involves the pleura covering the affected lobe, and that pleurisy affects 
a peripheric zone of lung tissue. The secondary process subsides to 
leave the main inflammation dominant. Actual pleuritic effusion 
occurs in about five per cent of cases of pneumonia. When the 
pleurisy and pneumonia occur simultaneously the pleurisy is said 
to be parapneumonic; when the pleurisy follows the pneumonia it is 
said to be metapneumonic. 

Forms of pleurisy are distinguished by 
the amount and character of the effusion. 
Cases in which the effusion is slight or ab- 
sent are known as pleuritis sicca; cases with 
perceptible effusion as pleuritis humida, or 
pleurisy with effusion. The effusion is dis- 
tinguished as serous or sero-fibrinous, puru- 
lent, sanguineous, or ichorous, according as 
it contains pure serum, fibrin, blood, or 
ichor. Forms are also separated into acute 
and chronic, and subvarieties of these forms 
into those which develop with the most in- 
tense symptoms, pleuritis acutissima, and 
those which develop so insidiously as to 
have remained latent for a long time. Most 
of these last cases belong to tuberculosis. 

Symptoms. — Pleuritis begins as an acute infection — i.e., with a 
chill or a series of shivering fits attended with rise of temperature. 
The fever is quickly followed by pain. The pain is usually pretty 
strictly circumscribed and is localized in the region of the left nipple. 
The pain is manifest in places where the layers of the pleura are sub- 
ject to most friction. The base and apices of the lungs remain at 
comparative rest. The sides are subject to most motion. The pain 
is present in every degree of intensity. The distinctive pain of pleu- 
risy is usually acute. It stops the movements of the chest and checks 
the act of respiration. Respiration becomes chiefly abdominal. The 
patient learns to spare the chest, sometimes to limit the excursion 
of the affected side. There is, however, along with the pain of pleu- 
risy, no increase in the frequency of respiration, so characteristic 
of pneumonia. The patient can take a long breath. It is plain to 




Fig. 233.— Limited expansion of 
chest on left side. 



PLEURISY. 545 

see that the inhibition of respiration is not a matter of inability or in- 
capacity, but of pain. The patient lies on the sound side in relief of 
pressure on the affected side. Later, when effusion takes place, the* 
patient changes posture to lie on the affected side, that the sound 
side may expand to secure more full inspiration. With the pain 
there is cough, dependent upon irritation of the pleura. That cough 
may result from direct irritation of the pleura is a fact with which 
clinicians may become familiar in the treatment of this disease. It 
may become necessary to remove a drainage tube in relief of a cough 
so harassing as to prevent sleep. Expectoration is absent, scanty, 
or purely bronchial. The disease is said to exist now in its first 
stage. At this time inspection reveals only limitation in the move- 
ments of the chest. Percussion gives no sign. Auscultation reveals 
the friction sound, a fine subcrepitant rale, striking on account of 
its superficiality, and circumscribed about the region affected. In a 
simple pleurisy the friction sound is transitory. It may be present 
for but a few hours or a day. It disappears under adhesion, effu- 
sion, or resolution. It may return with the reabsorption of fluid, 
which renews contact of inflamed and roughened surfaces. 

With the second stage of the disease, the stage of effusion, the 
physical signs change. When the effusion is very rapid, inspection 
will show more distinct interference with respiration. The brea th ing 
is increased in frequency. The pulse becomes irregular from in- 
terference with the circulation by pressure upon the great vessels. 
Some cyanosis may show itself . Where the effusion is great the 
affected side of the chest may bulge, the intercostal spaces become 
more prominent. The abdomen itself protrudes from depression of 
the diaphragm by the weight of the effused fluid. It is observed 
that the apex of the heart is displaced toward the right if the effu- 
sion be on the left side, toward the left if on the right side. Slight 
displacement of the apex of the heart to the right is observed before 
the accumulation is so great as to account for it by mechanical dis- 
placement. It is attributed to the altered resiliency of the lung on 
the affected side. The accumulation of fluid may be followed up by 
percussion. Change of posture reveals the fact that the fluid is free. 
It floats about as determined by gravity. The dulness in the back 
becomes resonance by placing the patient on the face, etc. Finally, 
the lung is compressed as an airless cake against the spinal column. 
Auscultation reveals nothing. But muffling or entire absence 
of sound % testimony more valuable than sound itself . In the re- 
gion of the compressed lung, particularly between the scapula and the 
spine, bronchial respiration is audible and bronchophony is dis- 
tinct. Finally, frem itus and resonance are both either dim inished 
or absent over the affected lung. A peculiar tremulous note, known 



546 PLEURISY. 

as cegophony, may be heard just above the level of the fluid. It is pro- 
duced, not by the fluid itself, but by laxity of the lung tissue. Bac- 
celli claimed that a whisper could be heard through a clear fluid, but 
not through a fluid rendered turbid by pus. Rumino believes this sign 
to be reliable — an opinion to which most clinicians fail to subscribe. 

Usually the fluid is serous or sero-fibrinous. It is not uncom- 
monly purulent. It is a question if the effusion is purulent from the 
start. It may certainly become purulent in the course of a very few 
days. The change is usually indicated by increase of the fever. 
The temperature, which may have been before but 100° to 102°, now 
rises to 103° or 104°, especially in the evening. The patient loses 
appetite and strength, becomes restless and sleepless. These symp- 
toms often signify the change to pus. Very frequently the change 
is so gradual as to be unannounced. The clearest serum contains a 
corpuscular element. Aspiration observations reveal the fact that a 
fluid clear at first becomes often milky toward the close. Corpuscles 
sink by their weight to occupy the lower strata. In most cases the 
character of the fluid can be determined only by withdrawal through 
an aspirator or a clean hypodermatic syringe. Cases due to advanced 
tuberculosis, as to irruption of a vomica into the pleural sac to con- 
stitute pneumothorax, often show ichor. Where the effusion con- 
tains blood the disease is usually either tuberculosis or cancer. There 
is in these cases corresponding cachexia and degradation. It is by 
no means always easy to distinguish the kind of fluid in the chest by 
the physical signs. Aspiration makes the diagnosis easy. Punc- 
ture with a perfectly clean instrument under aseptic precautions, 
which consist merely in washing the skin with soap and a sublimate 
solution 1 : 1000, is always justifiable in an obscure case. Failure to 
withdraw fluid does not necessarily exclude pleurisy. The case may 
be a pleuritis sicca, or effusion may have been absorbed to leave thick 
membranes. The needle sometimes becomes plugged with a flake of 
fibrin ; hence the aspirator, with its great suction force, is to be pre- 
ferred to the hypodermatic syringe. 

The diagnosis is determined by the pain in the side, the fever, 
decubitus, limited respiration, friction sound, and signs of effusion. 
The effusion is itself diagnosticated absolutely only by puncture with 
the hypodermatic needle or aspirator. 

Pneumonia is distinguished by higher fever, cough, expectoration 
of rusty sputum, crepitation, dulness to percussion unvaried by pos- 
ture, bronchial respiration, etc. 

Hydrothorax is separated by its cause, heart disease, kidney dis- 
ease, etc. It is bilateral, painless, free of fever, and furnishes to 
puncture a clear, light-yellow fluid, free of flocculi, of light specific 
gravity, less than 1018. 



EMPYEMA. 547 

The prognosis depends upon the cause. Simple pleurisy has a 
favorable prognosis. Tubercular pleurisy is always grave, yet cases 
do recover absolutely. 

It is essential to distinguish the form of the disease, as the treat- 
ment depends upon it. Simple cases are let alone. The case is 
treated on the expectant plan, or, with the doctrine of rheumatic 
origin, by the salicylates, precisely as in acute rheumatism. Fiedler 
stoutly claims that early treatment with the salicylates aborts the 
disease. Pain is relieved by hot applications — i.e., hot water — 
investing the whole side of the chest. More severe pains may re- 
quire broken doses of Dover's powder gr. ij.-vj., or morphia itself 
gr. i~ J. Under rest and relief of pain the fluid is absorbed sponta- 
neously. Cases of pneumonic or tuberculous origin, unduly pro- 
tracted cases of any kind, and all cases of pleuritis acutissima, de- 
mand aspiration of the effusion. Nature should be. first allowed a 
chance for two or three weeks. Persistent fever, progressive failure 
in health and strength, weight and color and appetite, command the 
operation. The puncture should be made in the fourth left, fifth 
right intercostal space, and the fluid slowly but never wholly with- 
drawn. 

EMPYEMA. 

Empyema (€/J7tv?'/jua, an internal suppuration) ; suppurative pleu- 
risy. — The fluid effused in pleurisy, though it may seem perfectly 
clear, always contains corpuscular elements. These elements may 
be so few as to escape observation altogether. As the case pro- 
gresses, more especially after frequent paracentesis, the corpuscles 
accumulate, until finally the fluid becomes milky and the serum is 
said to be converted into pus. It is a frequent observation that, 
though the fluid may be clear at first, it later becomes more opaque. 
The first syringefuls may be clear serum, the last purulent. This 
change may take place rapidly or slowly ; sometimes the fluid is puru- 
lent from the start. This condition occurs more frequently than is 
commonly believed. Most of the cases of secondary pleurisy, as in 
the course of pyaemia, after violent dysentery, etc., are purulent from 
the start. This form of pleurisy is known by a different name — em- 
pyema. It has a different prognosis and requires a different treat- 
ment. The character of the fluid is determined by the primary or 
superadded cause of the disease. The organisms most frequently 
encountered are the streptococcus, staphylococcus, pneumococcus, 
diplococcus, and tubercle bacillus. 

Certain symptoms may indicate the period of accumulation or 
formation of pus. Fever shows itself, or increases if present before. 
It is especially wont to assume a remittent type with exacerba- 



-548 



EMPYEMA. 



tions at night. The patient loses what appetite he had, becomes 
restless, sleepless, suffers pain. It is plain to see that he is losing 
ground. Frequently the change takes place so insidiously as to 
escape notice. Sometimes the disease is perfectly latent, or, if de- 
cline be noticed, the diagnosis is dubbed tuberculosis and dumped 
into the heap of so-called incurable diseases. Empyema is in gene- 
ral much more common in childhood. Empyema is an internal 
abscess. Pus may not remain with impunity within the cavity 
of the chest. The pus of empyema has special erosive properties 
and may cut its way to the surface. In these cases it generally 
perforates at the thinnest place, near the sternum. It perforates 
the parietal layer, insinuates itself between fibres of the intercostal 
muscles, and appears as a subcutaneous abscess, where it shows it- 
self in surface redness and oedema. When the track of perforation 

is straight the outside abscess is seen 
to expand and contract under move- 
ments of expiration and inspiration. 
Sometimes it conveys the impulse of the 
action of the heart. Ordinarily the 
track is more oblique and irregular, to 
form a kind of valve which permits only 
the escape of fluid accumulated within; 
or the surface may be more directly per- 
forated, sometimes b}^ a number of ori- 
fices, to permit rapid escape, or, more 
frequently, the long- continued oozing 
out, of pus. Such a case is an ' ' em- 
pyema necessitatis/' 

In other cases the pus penetrates in- 
wardly ; it attacks and erodes the visceral pleura. The lung may 
now take it up and like a sponge become saturated with pus, or, 
more frequently, the bronchus is invaded and the contents of the 
pleural sac are poured into the bronchial tubes to issue in quantities 
from the mouth. An empyema may empty itself in this way. The 
pleural sac may thus become obliterated, or reaccumulation occurs 
with renewed discharge. Such patients who discharge with bron- 
chial cough, at intervals, large quantities of pus, are often regarded 
as tuberculous. 

The sputum in these cases is distinguished by the presence of 
crystals of leucin and ty rosin. Leucin occurs as globular masses, 
tyrosin as needle-shaped crystals peculiarly arranged in bundles. 
These bodies are degenerated products of albuminoid bodies de- 
veloped in pus under exclusion of air. Hence they may be regularly 
-encountered in a perforating empyema. But they are usually pre- 




Fig. 234. — Tyrosin in needle-shaped 
crystals arranged in bundles and stel- 
late groups. 



EMPYEMA. 549 

sent in solution, and may be seen, therefore, only when the sputum 
dries, as they are deposited in characteristic form about the border of 
the object glass. Leucin looks like fat globules, but is distinguished 
by its insolubility in ether (Graber). 

The discharge through the bronchial tubes is the most favorable 
event which may occur spontaneously in the history of empyema. 
In rarer cases pus may penetrate the diaphragm and insinuate itself 
along the spine behind the peritoneum, to appear as an abscess at the 
groin on the inner aspect of the thigh, where it may be mistaken for 
a sinking abscess from vertebral caries. As curiosities may be 
mentioned cases in which pus breaks directly into the pericardium or 
peritoneum, or by fistulae into the perineum, etc. 

Treatment. — Cases of pleuritis acutissima call for immediate re- 
lief to prevent suffocation. In these cases pain is intense, dyspnoea 
is pronounced, the pulse is excessively weak, collapse is imminent. 
Weil collected seventy -five cases of sudden death in the course of 
acute pleurisy, due to compression of blood vessels, pulmonary throm- 
bosis, and heart failure. 

How long fluid may be permitted to remain in the chest is a ques- 
tion that must be decided in the individual case. Where the patient 
is doing well, as determined by the pulse, respiration, and general 
appearance, the case may be let alone. Spontaneous absorption, even 
of pus, is the rule in childhood. Should, however, great change 
be noticed in any way, the fluid should be withdrawn, and in no 
case should it remain longer than two to three weeks for fear of com- 
pression of the lung. Paracentesis is best performed by aspiration 
with a needle, whose cleanliness is secured by having been boiled 
five minutes. The surface is rendered aseptic with a 1 : 1000 subli- 
mate solution, having been first cleaned with soap and water. The 
needle is then plunged between the ribs in the axillary line at the 
fifth, sixth, or seventh intercostal space, near the upper border of 
the lower rib, to prevent wounding an artery or nerve. Where 
the fluid is known to be a pure serum the finest needle may be em- 
ployed. When a previous aspiration has revealed the fact that the 
fluid is thick or contains flakes, a larger needle must be used. The 
presence of fluid is usually discovered at once with the first attempt, 
but accumulation or thick membranes may require repeated punc- 
ture. The fluid is in no case to be withdrawn wholly. The opera- 
tion should be checked at once upon the supervention of any irregu- 
larity in the action of the heart, pulse, respiration, or severe cough. 
The face should be as closely watched for any sign of syncope and 
the chest for any evidence of dyspnoea as in the inhalation of chloro- 
form. Sudden death has occurred from heart failure, from throm- 
bosis, or from sudden obstruction of the air cells. The fluid is 



550 PNEUMOTHORAX. 

withdrawn slowly, that the lung may follow it in expansion, or that, 
where this is impossible, the chest may undergo retraction. With 
these precautions the operation is simple and safe. A large accu- 
mulation of fluid may necessitate rapid operation. Empyema in a 
child may terminate, as stated, of itself, and hence should be allowed 
to run a little longer. In adults the operation is made at once. The 
patient is put in a semi-recumbent posture, inclined toward the op- 
posite sound side to separate as much as possible the imbricated 
ribs. A piece of skin is pinched up between the fingers, transfixed, 
and severed by a bistoury from below upward. A subcutaneous 
injection of the solution of cocaine may substitute an anaesthetic. 
The rib may or may not require resection — always a simple, but for 
the most part a superfluous, procedure. The knife is then plunged 
into the pleural sac. Pus usually spurts out in quantity with much 
gurgling and sound of insufflation, which speecfily subsides to give 
place to a profuse discharge. A perforated tube is now inserted, 
or, better, a roll of iodoform gauze, and the case, with cleanliness, 
may be left to itself. Irrigation is no longer considered necessary. 

PNEUMOTHORAX. 

Air may penetrate to the pleural sac from without, as through 
penetrating wounds, or from within after rupture of the visceral 
pleura, to constitute pneumothorax. In more than three-fourths of 
cases the condition is caused by tuberculosis of the lungs and repre- 
sents irruption from a cavity. In exceptional cases pneumothorax 
may result from empyema or from abscess or gangrene of the lungs ; 
still more rarely from disease of the oesophagus, stomach (gastric 
ulcer), or intestine. As a rule the connection with the lungs subse- 
quently closes and the enclosed matter, air, serum, blood, or pus, be- 
comes encapsulated. Sometimes it remains open or is closed by a 
valve. 

In consequence of the connection with phthisis, pneumothorax oc- 
curs twice as frequently on«the left side, and is found oftenest in the 
acute or subacute cases with rapid advance. Double pneumothorax 
is extremely rare. 

Symptoms. — The condition is usually announced suddenly ; some- 
times after effort, muscular strain, or cough ; with intense pain, 
anxiety, and extreme dyspnoea, cyanosis, and heart failure, to 
constitute a picture of deep distress. Collapse of the lung, with dis- 
placement downward of the diaphragm and abdominal organs, are 
direct results of pressure. The heart's action is barely perceptible, 
the pulse is reduced to a thread. CEdema of the hand of the affected 
side is a striking symptom which stamps the character of the af- 
fection in certain cases ; when it occurs it shows itself early, and, as 



HYDROTHORAX. 551 

a rule, rapidly disappears (Weil). After empyema pus may be ex- 
pectorated. Inspection reveals distention, sometimes surface em- 
physema. The heart's apex is displaced downward, and to the right 
in left-side affections, to the left in right-side affections. Resonance 
and fremitus are diminished or lost. Percussion shows tympan- 
ites, which is diminished under extreme distention, with low dulness 
over the displaced liver and spleen. Nothing is to be heard under 
auscultation. The vesicular rale is suppressed. Various cavernous, 
amphoric, metallic sounds are sometimes to be heard somewhere or 
over various parts of the chest. Auscultation during percussion ap- 
preciates metallic sounds. The presence of fluid in the cavity of the 
chest substitutes dulness for resonance or tympanites. The dropping 
of fluid may be recognized sometimes as metallic tinkling, or the 
play of air through valve openings and fistulse, " water-pipe" sounds, 
are more or less distinctly audible. Agitation of the body may 
furnish splashing sounds — succussion. 

The prognosis is always grave, but depends upon the cause, 
more especially upon the extent or advance of the phthisis. While 
the patient may sink into a fatal collapse in the attack, he may never- 
theless recover from aggravated forms. According to West seventy- 
five per cent of cases succumb within fourteen days, ninety per cent 
within a month. 

Treatment. — Pain must be relieved by morphia and hot applica- 
tions ; large flannels wrung out of excessively hot water may sur- 
round and envelop the whole of the affected chest. The pain, dysp- 
noea, and anxiety of extreme distention may necessitate paracentesis 
with an aspirator needle or a fine trocar. The strength must be sus- 
tained with stimulants — alcohol ; soda benzoate of caffeine three 
grains every hour, internally or subcutaneously ; digitalis. Witzel 
recommends the displacement of the noxious matters in the chest by 
the injection of the sterilized physiological solution of common salt. 

HYDROTHORAX. 

Fluid, serum, is effused into the cavity of the chest in conse- 
quence chiefly of heart and kidney disease, and the condition is an ex- 
pression of general dropsy. Effusion takes place in slighter amount 
in consequence of marasmus, compression of the great lymph or 
blood vessels, thoracic duct, intrathoracic veins, as by aneurism, 
tumors of the mediastinum, etc. The effusion is usually passive and 
bilateral, and is found in connection with anasarca, ascites, some- 
times with oedema of the lungs, etc. The fluid is clear, yellowish, 
often with a greenish tinge, alkaline, free of flocculi. The specific 
gravity is light, 1010-1012. 

The diagnosis rests upon the recognition of the cause, more 



552 PERIPLEURITIC ABSCESS. 

especially upon the physical signs, which do not differ from those of 
pleurisy with effusion, save that the effusion in hydrothorax is bi- 
lateral. In all cases of doubt the diagnosis is determined by 
aspiration. 

The prognosis and treatment depend upon the cause. Exces- 
sive dropsy, with the danger of asphyxia, is relieved by caffeine, 
digitalis, diuretin, especially by calomel, as in the treatment of heart 
disease. It is sometimes necessary to drain the legs. 

HJEMATOTHORAX. 

Heematothorax, as the name indicates, is the presence of blood in 
the pleural sac, *as the result sometimes of penetrating wounds, or of 
fracture of a rib with rupture of an intercostal artery ; much more 
frequently of discharge from a cavity with eroded blood vessels, in 
tuberculosis. The blood in these cases is usually mixed with pus, 
sometimes also with air or gases, to constitute a pyohsematothorax or 
a pneumopyohsematothorax. The condition is not to be confounded 
with the bloody effusions of tuberculous or cancerous pleurisy. 

Prognosis. — The blood from a penetrating wound may be ab- 
sorbed and the patient may recover. The prognosis after rupture 
of an aneurism is fatal ; the patient succumbs to internal haemor- 
rhage. The prognosis in cases of tuberculosis, where the condition 
is associated with pyothorax or pneumothorax, is exceedingly 
grave. 

The treatment does not differ from that of pneumo- or hydrotho- 
rax. It must have reference to the cause — tuberculosis, aneurism, 
etc. 

PERIPLEURITIC ABSCESS. 

Peripleuritic abscess is a rare condition, first recognized by Wun- 
derlich, afterward more thoroughly described by Bartels, which 
results most frequently from the invasion of actinomyces, but may 
arise independently from unknown cause. Peripleuritic abscess gives 
rise to symptoms which have led to confusion with pleuritic effusions, 
empyema, in that both affections distend the chest. A point of dif- 
ferentiation is the fact that the ribs are separated, in abscess, at the 
seat of the greatest accumulation of pus, while they are crowded 
together in other regions, whereas in empyema the distention and 
separation are uniform. The intercostal spaces, or abscess wall, 
retract or become lax on inspiration and tense on expiration, 
whereas they remain unaffected in empyema. There may be fluctu- 
ation in abscess, absent in empyema. The abdominal organs are 
displaced in abscess; the pus itself has a lighter specific gravity, 
maximum 1032 in empyema, minimum 1040 in abscess. 

Treatment consists in the discharge of the abscess. 



SUBPHRENIC ABSCESS. 00 6 



SUBPHRENIC ABSCESS. 



Abscess below the diaphragm, the result of ulcer of the stomach. 
disease of the liver, upward wandering paranephritic or peri- or 
paratyphlitic abscess, or the result of ernpyemata whose products 
have been carried by lymph vessels through the diaphragm, etc., 
forms collections above the liver or spleen, sometimes of considerable 
magnitude. The diagnosis is established, in connection with the pre- 
vious history, by means of the aspirator. Treatment is the discharge 
of the pus or other surgical intervention. 



DISEASES OF THE 

ORGANS OF CIRCULATION. 



CHAPTER VII. 

DISEASES OF THE HEART. 
PERICARDITIS. 

Pericarditis. — Infection of the pericardium in the course of some 
mycosis or inflammation by extension of disease from some con- 
tiguous viscus. 

History. — The ancients considered hairy hearts (fibrinous de- 
posits) evidence of courage. The earlier anatomists could not fail to 
find the evidence of pericarditis in effusion. Galen saw it in animals 
and suspected it in men. Rondelet recognized it under the symptoms 
of pain, difficulty of breathing, and fever, with attacks of fainting. 
Riolan went so far as to suggest withdrawal of the fluid in cases of 
effusion, and described the symptoms as being more dangerous than 
those of pleurisy or pneumonia. Vieussens relates that he often 
encountered adhesion of the two layers of the pericardium. There 
was as yet, however, not sufficient knowledge to enable a diagnosis 
to be clearly established in life. Morgagni declared that the day 
was distant when the ability to recognize the disease would justify 
the operation of puncture of the pericardium. Avenbrugger noticed 
bulging of the praBcordium and increase of percussion dulness. How 
little these discoveries contributed to a diagnosis may be learned by 
the fact that even Laennec (1819) doubted the possibility of making 
an accurate diagnosis. Collin (1824) discovered the friction sound, 
which at once made the recognition of the disease general property. 
Later contributions have more to do with the etiology of the affec- 
tion. 

The frequency of occurrence of pericarditis is best shown by sta- 
tistics from hospital practice, where accurate records are kept and 
full autopsies are held in all fatal cases. According to the report 
of one year, 23,249 cases of disease of all kinds were treated in 



PERICARDITIS. 



555 



the General Hospital in Vienna. Of this number 551, about one- 
fortieth of the whole number, were cases of rheumatism. However, 
but 390, about one-sixtieth, were cases of rheumatism of the joints. 
Pericarditis occurred 32 times, or once in every 726 cases of disease 
of all kinds. The point of especial interest is the fact that the peri- 
carditis was a sequel or consequence of rheumatism in but 6 cases, 
while in 26 cases — that is, five times as often — the disease depended 
upon other causes. Endocarditis on this occasion occurred but 15 
times. Pericarditis was, therefore, in that year twice as frequent as 
endocarditis. This ratio may have been an accident, or it may be 
that endocarditis only seems more fre- 
quent because it leaves valvular lesions. 
Patients recover or die of pericarditis 
quickly, as a rule. Cases do not accu- 
mulate as in endocarditis. The older 
statistics, based simply upon clinical ob- 
servation, speak for the greater fre- 
quency of endocarditis. Thus Sibson's 
record shows three times as many cases 
of endocarditis. But clinical observa- 
tions can give no precise information 
regarding the frequency of pericarditis, 
for the very reason that the disease, so 
often latent, is overlooked. 

Exact information in this respect can 
come only from the dead-room. Duchek 
claims to have found evidences of peri- 
carditis 89 times in 590 post-mortem 
examinations — that is, in a fraction over 
fifteen per cent of all the autopsies made 
— but this ratio must be regarded as an 
overestimate, for the reason that Duchek included in his diagnosis 
the cases of so-called milk spots, which are now no longer regarded 
as pericarditis. But, with due allowance for the tendinous spots, 
which are especially frequent in age, when true pericarditis is espe- 
cially infrequent, it is seen that pericarditis is a comparatively fre- 
quent disease. Perhaps the statement of Willigk that pericarditis is 
encountered in four per cent of autopsies is nearer the truth, in that 
this statement is based upon observations made during the earlier 
periods of life. Later observations only serve to confirm the state- 
ment of Bauer to the effect that "formerly, and up to the close of 
the last century, pericarditis was considered a rare disease; since then 
it has been proved to be of quite frequent occurrence." 

Etiology. — It is universally conceded that pericarditis occurs 




Fig. 235.- 
pericarditis. 



Cor villosum. Fibrinous 



556 PERICARDITIS. 

oftener among males than females. Of the thirty- two cases cited 
from the Vienna hospital, twenty -three were males. Louis says of 
his one hundred and six cases that only one-fourth were females, a 
ratio which agrees with the observation of Hache. Bamberger's 
ratio was thirty-eight males, twenty-five females. Sibson, who saw 
the largest proportion of females of any author, observed neverthe- 
less the preponderance of males; of his sixty-three cases, thirty-five 
were males, twenty- eight females. This ratio points to the greater 
liability of males to the diseases which cause pericarditis. 

Excluding the cases of so-called tendinous spots, which are now 
regarded as simple friction scleroses or hyperplasia of senescence, it 
is as generally admitted that pericarditis is a disease of youth and 
maturity. Grisolle and Bamberger unite in the statement that the 
maximum frequency of the disease occurs between the ages of twenty^ 
and thirty. 

The relation»of occupation to pericarditis has been best shown by 
Sibson, who observes that ' ' servants formed f ully two-thirds of the 
whole of the female patients affected with pericarditis." It is inte- 
resting to note of Sibson's cases that pericarditis occurred in none of 
his females of sedentary occupation, needlewomen, etc. The influ- 
ence of hard work is still further proven in the study of his male 
cases. 

Pericarditis is described as primary and secondary in its nature, 
and much confusion exists as to what is meant by primary pericar- 
ditis. If by primary is meant a spontaneous or autochthonous in- 
flammation, the term should be discarded altogether, for it may be 
said that pericarditis never arises in this way. Pericarditis is, strictly 
speaking, always a secondary or deuteropathic malady. There are 
met, it is true, occasional cases where the cause has not been or can- 
not be discovered, but these cases should be labelled inexplicable or 
cryptogenetic rather than primary. All modern writers agree as to 
the great rarity of so-called primary pericarditis. Duchek saw only 
one case in eighty-nine, Bamberger but four in sixty-three. Fried- 
reich, with his wide experience, met but two cases in which he 
could discover no cause for the disease. Since the field of "catch- 
ing cold " is being daily more and more contracted in the etiology 
of disease, it is wiser to be agnostic regarding inexplicable cases than 
to appeal to doctrines incapable of demonstration and hence bound 
to become obsolete. 

An etiological division of cases more in accord with existing 
knowledge would be into consecutive {or mechanical) and infectious 
(or mycotic). Under the head of consecutive origin would fall the 
cases of insult or injury to the pericardium from without, as by 
traumata, by perforation from a gastric ulcer, from the oesophagus, 






PERICARDITIS. 557 

from an abscess of the spleen, from pulmonary and pleuritic pro- 
cesses, echinococci, aneurisms, caries of the vertebrae, sternum, and 
ribs, mediastinal affections, inflammations of the mammae, skin dis- 
eases — in short, all involvements of the pericardium by contiguity or 
continuity of structure, including under this head also extensions of 
inflammation from the heart itself. 

While these cases of so-called mechanical origin form a respect- 
able contingent of all the cases, they nevertheless remain in the mi- 
nority, all combined, when compared with the inflammations or pro- 
cesses secondary to the infectious diseases. 

The pericardium is not alike affected by all infections. Certain 
forms of them show distinct predilection for this structure, and so 
notoriously is this true of acute articular rheumatism as to lead 
many practitioners to exclude pericarditis in its absence. It is un- 
doubtedly true that acute joint rheumatism remains the most promi- 
nent factor in the etiology- of pericarditis, that it causes, or is at- 
tended with, more cases than any other one factor — Bamberger 
claims that thirty per cent, Chambers and Thompson sixteen and 
twenty per cent, of cases arise from rheumatism — but it is equally 
true that there is no other acute infection which may not be followed 
by pericarditis. 

If pericarditis is to occur in rheumatism it shows itself by pre- 
ference between the fourth and fourteenth days of the disease. 

While it is always a possibility in mild, brief, or protracted 
cases, the rheumatisms marked by severity or fugacity are rather 
more liable to entail pericarditis. With endocarditis it occurs far 
more frequently in the young. 

Next in frequency in the pathogeny of pericarditis comes pleu- 
risy. Morgagni and Corvisart remarked this complication in their 
day. Duchek claims to have seen in forty-three cases of fresh peri- 
carditis an associate pleurisy twenty-two times : but, inasmuch as 
the freshness or age of the pleurisy is- not remarked, it is fair to infer 
that the order of sequence, in some of the cases at least, may have 
been reversed. In Bamberger's cases of pericarditis 10.5 per cent 
arose from pleurisy and pneumonia. 

Tuberculosis affects the pericardium in both ways. That is, the 
process may by contiguity inflame, or a vomica open up, the peri- 
cardium, to produce the disease in a mechanical way. Or the micro- 
organisms of tuberculosis may lodge and multiply upon the serous 
surface, just as upon the cerebral meninges or tunica vaginalis, as 
conveyed thither in the lymph and blood supply. Bamberger's sta- 
tistics show pericarditis in fourteen per cent of cases of pulmonary 
phthisis, but it is impossible to eliminate the role of pleurisj" in any 
of these cases. 



558 PERICARDITIS. 

Statistics are wanting declaring the relative frequency of peri- 
carditis in the various acute infections, yet it is known of nearly all 
of them that this complication does occur. 

In pyaemia and septicaemia, as typically represented in traumata, 
puerperal fever, and prostatitis, pericarditis with its frequent as- 
sociate, endocarditis, is the complication which directly or indirectly 
is the most frequent immediate cause of death. It occurs in all 
three forms of typhus — the exanthematic, recurrent, but most rarely 
in the abdominal form. Measles, scarlet fever, and small-pox are 
attended with pericarditis occasionally only in the less severe, as a 
rule in the malignant, forms of these diseases. It is not very rare 
in cholera, and is quite common in epidemic dysentery, along with, 
or independent of, the rheumatism which sometimes follows dysen- 
tery. In erysipelas, diphtheria, cerebro-spinal meningitis, pericar- 
ditis not infrequently constitutes the last link in the chain of disease 
process. These are all diseases of mycotic origin. 

But pericarditis may ensue upon even the lightest infections. 
Perhaps the most interesting illustrations of this fact are those of 
Bednar, who several times observed pericarditis after vaccination. 
In one case an acute dermatitis developed in twenty-four hours after 
vaccination, with a simultaneous pericarditis. In a second case— a 
sharp diarrhoea — subcutaneous abscesses and pericarditis proved the 
order of sequence. In a third case the pericarditis developed on the 
thirteenth day after vaccination, without intervening disease. 

In Bednar's thirty-six cases of pericarditis the disease was found 
independent of other demonstrable lesions only four times. Thirty 
of these cases occurred within the first month of life, four in the 
second, and one in the third and fourth months. In all cases the 
disease was attributable to puerperal processes in the mother, which, 
in the author's words, " extended their injurious effects to the child, 
and, in consequence of acute decomposition of the blood, developed 
fibrinous or purulent exudations in various organs and frequently 
in the pericardium. The disease proved fatal, as a rule, within the 
first sixteen days of life." 

Pericarditis shows itself in forms distinguished as primary and 
secondary, and acute and chronic ; but the forms of practical in- 
terest are those attended or not with effusion. 

Symptoms. — Few of the signs upon which the recognition of the 
disease is based are local. The disease is generally recognized by 
general signs. Pain is not a prominent factor in the history of peri- 
carditis. It may be present as a more or less diffuse distress, but is 
manifest rather upon pressure than spontaneously. 

On account of disturbance in the action of the heart itself there is 



PERICARDITIS. 559 

often precordial anxiety, as manifest in the physiognomy of the 
patient. Pericarditis sicca runs, as a rule, a latent and unsuspected 
course, and the diagnosis is only established by auscultation. The 
friction sound may often be heard anywhere over the heart, most 
intensely over the body of the heart at the left border of the ster- 
num. In simple pericarditis from rheumatic cause it is often very 
transitory and may exist during the space of but a few hours. The 
earlier writers described it as a to-and-fro sound, corresponding with 
the contraction and dilatation of the ventricles. While it is there- 
fore a double sound, it is not strictly synchronous ivith the sounds 
of the heart. It may change or disappear by change of posture, by 
pressure of the stethoscope, and is often intensified by the act of 
holding the breath. It varies in every degree of intensity from a 
whisper to the creaking of new leather, and seems to be, as compared 
with heart murmurs, exceedingly superficial, as if just under the 
ear. It disappears naturally (1) in the process of resolution, (2) with 
the separation of the membrane by effusion, and (3) with adhesion 
of apposed surfaces. 

In pericarditis from tuberculosis or from mechanical cause the 
surface is wont to be much more roughened and the sound coarser 
and more persistent. Having disappeared under effusion, it may re- 
turn asa a redux rub " after absorption of the fluid. 

Pericarditis with effusion is much more readily recognized. In 
slight amount up to a few ounces the effusion may escape detection. 
ISTot infrequently the first sign of effusion is interruption of the fric- 
tion sound. As a rule effusion reveals itself by the general disturb- 
ance in circulation and respiration. Where the process is slow, 
tolerance is established and effusion is arrested in the course of a 
few hours or a few days at a point which does not materially inter- 
fere with the action of the heart. The fluid may now be absorbed 
and the disease disappear without having even been recognized in 
life. The effusion is, however, more wont to become persistent or 
permanent in the pericardium than in the pleura, and under any 
greater accumulation signs of general distress more or less rapidly 
supervene. The heart's action becomes weaker, the pulse is feebler. 
There is pallor, ivith prostration, dyspnoea, sometimes cyanosis 
and syncope. 

A case strikingly illustrative of these points occurred in the expe- 
rience of the author. The patient had been the victim of unsuspected 
pericarditis with effusion for fifteen years — at least the same symp- 
toms had been present in greater or less degree all that time. The 
prominent symptoms were pallor, dyspnoea, such vertigo as to com- 
pel the recumbent position, occasional cough, and a pulse so feeble 
as to fade away when the arm was held at right angles to the body. 



560 PERICARDITIS. 

Digitalis and alcohol administered from time to time obviated immi- 
nent collapse. There was undoubted increase of dulness over the 
region of the heart, which had been taken for dilatation. By aspira- 
tion one pound of serum, at first clear, later brownish and flocculent, 
was withdrawn from the pericardium. The symptoms of immediate 
danger soon disappeared. But the long pressure and maceration had 
weakened the walls of the heart to such an extent as to prevent per- 
fect recovery. 

The diagnosis in these cases is 
established for the most part by the 
physical signs. Inspection shows, 
in the chest of the young, bulging, 
and palpation reveals muffling or 
absence of the impulse of the heart. 
The to-and-fro friction sound is 
characteristic. The most valuable 
signs are disclosed to percussion. 
There is dulness over the entire 
prsecordium, corresponding to the 
distended pericardial sac. When 
this dulness is outlined upon the sur- 
face of the chest it is seen to consti- 
tute a truncated cone, whose base 
is at the diaphragm and whose trun- 
cated apex corresponds to the at- 
tachment of the pericardium about 
the great vessels. Fluid accumu- 
lates usually to the extent of a pint 
or more, and such accumulation 
gives rise to distinct dulness over 
the whole left front of the chest. In 
the absence of tuberculosis or apex 
placement downward of the liver. pneumonia, dulness under the clav- 

icles, beginning at the second or 
third rib and extending downward and outward, should always ex- 
cite suspicion of pericardial effusion. Occasionally the accumulation 
is so great as to conceal a great part or the whole of the lung which 
it oppresses by its weight. 

Andral once discovered two pounds of blood, Corvisart ^ once 
found eight pounds of serum, and Alonzo Clark reported the history 
of a case where the pericardium contained one gallon of sero-puru- 
lent fluid. The distention which the sac must undergo to accommo- 
date such quantities becomes evident with the statement of the nor- 
mal capacity, fourteen to twenty-two ounces in the adult male. 




PERICARDITIS. 561 

The mental disturbances which have been described in connec- 
tion with pericarditis are due either to interference with the circula- 
tion of the blood in the brain, or are toxic effects in connection with 
the original and originating maladies. With the history of a myco- 
sis, the previous occurrence of the friction sound, and the presence 
of dulness, the diagnosis is very simple, and failures in recognition 
of the diseases are due here, as well as elsewhere, to lack of exami- 
nation. 

Diagnosis. — The disease must be differentiated at times from 
pleurisy. Pleuritic friction sound corresponds to the acts of respira- 
tion, and is arrested when the patient holds his breath. In rare cases 
the pleura may be rubbed by the action of the heart. The diagnosis 
must be established, if the diseases are not associated, by a considera- 
tion of the other signs. Endocardial murmurs distinguish themselves 
from pericarditic friction sound by the fact that they are more strictly 
synchronous with the sounds of the heart. They are more uniform 
in intensity and are not affected by change of posture or pressure. 
They may be rendered more intense by exercise. Doubt regarding 
the nature of the effusion may be dispelled by puncture with the 
hypodermatic syringe. The needle should be introduced at the 
fourth, fifth, or sixth intercostal space, half an inch or an inch to 
the left of the sternum. Failure to secure fluid does not necessarily 
exclude its presence. The tube may be blocked by a flake of fibrin, 
or the fluid may be too thick to flow, so that subsequent puncture 
may be tried with the larger needle and greater force of the aspira- 
tor. It is needless to say that all needles used in this way should 
be previously rendered aseptic by boiling five minutes, best with 
sodium bicarbonate five per cent. Otherwise it is best to use no needle 
twice, but to employ a new needle for each occasion. Should the 
fluid show blood or consist largely of blood, the pericarditis is prob- 
ably tubercular or cancerous. Tuberculosis, however, by no means 
always shows a bloody fluid. It may be as clear as the product of 
a more innocent mycosis. It is a common observation that a fluid 
which is serous on the first withdrawal may become purulent later, 
or the fluid may be purulent from the start. 

A chronic adhesive pericarditis cannot be distinctly recognized 
by any special train of symptoms. The retraction at the apex of the 
walls of the chest by no means always occurs in this condition, and 
when it occurs does not necessarily indicate the adhesive change. 
The same may be said of the pulsus paradoxus — i.e., the decrease in 
the force of the heart which attends an act of inspiration. It is 
found also in many other conditions. 

The prognosis is always much more grave than inflammation of 
the pleura. Pericarditis sicca usually runs a favorable course, and 
36 



562 PERICARDITIS. 

though the membrane may be thickened by many layers and more 
or less adhesion produce a partial or complete obliteration of the 
pericardial sac, there need be no serious disturbance in after-life. 

The conditions are not so favorable for rapid or complete absorp- 
tion in pericarditis as in pleuritis. The fluid is more apt to remain, 
and lead in the course of time to maceration of the heart as well as 
interference with its action. 

Simple pericarditis without effusion requires little or no treat- 
ment. Rest in bed or out of it in the recumbent posture, the appli- 
cation of dry cups, an ice bag, or of moist heat, according to the 
sensations of the patient, with the time of a few days to a week, usu- 
ally dissipate the disease. The salicylates, in addressing the cause, 
are as valuable as in pleuritis. Any unusual pain may be relieved 
by broken doses of Dover's powder gr. iij.-v., or an extreme case by 
the use of morphia. Sleeplessness may be controlled by trional gi\ 
xv., or chloral gr. v., and nervousness by the bromides gr. xx.-xl. 
largely diluted. Effusion not too rapid or extensive may be allowed 
to remain, with the hope that it will disappear by absorption in the 
course of a few weeks. Should it persist longer, or accumulate so 
rapidly as to threaten suffocation, pericarditis acutissima, it must be 
withdrawn at once, under the same or even greater precaution as in 
pleurisy. 

The relief which follows the discharge of even a portion of this 
fluid is indescribable. The author has seen patients who have been 
confined to bed for a week, unable to lift the head without vertigo, 
recover to show a strong pulse, cheerful mien, appetite, and such 
increase of bodily strength in the course of a few hours as to enable 
them to sit up and actually leave the house in the course of the fol- 
lowing day. 

Delay in absorption may often be hastened by the administration 
of a laxative, preferably calomel in all affections of the heart. The 
remedy may be given, as in the treatment of dropsy, in doses of 
three grains three times a day, when benefit may be expected in the 
course of the third day. Purgation favors osmosis. Any sudden 
collapse of the heart would call for the analeptics, alcohol, camphor, 
digitalis, and, more especially for immediate effects, nitroglycerin. 

Protracted cases with slight effusion may have absorption has- 
tened by the use of blisters, which are much more efficacious in peri- 
carditis than in pleuritis, or by painting the surface with iodine, and 
friction with mercurial ointment. 

Tuberculosis of the pericardium is not infrequent. Bacilli 
may be carried directly by the blood vessels, or the disease may ex- 
tend by contiguity of structure from the lungs to the pleura. The 



ENDOCARDITIS. 563 

effusion may remain perfectly clear ; it is more frequently tinged 
with blood, and is sometimes, after caseation, purulent. 

Syphilis of the pericardium is very rare. It may occur in con- 
nection with disease of the heart muscle. 

Hydropericardium, pneumopericardium, hsematopericardium, 
pyocardium (water, air, blood, pus in the cavity of the sac), occur 
under the same conditions and require the same treatment as in the 
pleural sac. 

endocarditis. 

Endocarditis. — Infection of the endocardium. 

History. — Definite knowledge of disease of the endocardium 
could date only from the discovery of the circulation by Harvey 
(1628), following the accurate description of the construction of the 
heart by Yesalius. Nevertheless these discoveries were, not at- 
tended with immediate results, and it was almost a century later 
that Vieussens made mention of the first case of stenosis and insuffi- 
ciency of the mitral valve. Vieussens recognized also the enlarge- 
ment of the ventricle and alteration of the pulse, the result of this 
condition. Lancisi drew attention to the dilatation of the right ven- 
tricle and visible changes in the cervical veins. Albertini reinstated 
palpation in estimating disease of the heart, and Morgagni ascribed 
cyanosis to interruption of the circulation. Senac was the first to 
devote himself to the systematic study of disease of the heart. He 
noticed especially the influence of age and the occurrence of cerebral 
complications in heart disease. Corvisart reintroduced percussion, 
which had been neglected since the days of Avenbrugger, in the 
diagnosis of heart disease, and was the first, according to Laennec, 
to recognize fremitus as a symptom of valvular disease. Laennec 
illuminated the whole field by means of auscultation, and made it 
possible to distinguish the various , forms of valve disease in life. 
Rosenstein gives to Kreisig the credit of basing these diseases upon 
inflammation of the endocardium. Bouillaud baptized the disease 
with the name endocarditis, which still remains, and to him is due 
the credit of having especially emphasized the relation of this affec- 
tion to rheumatism. 

The work of subsequent investigators is more especially that of 
elaboration and refinement, up to the time of Yirchow, who for the 
first time gave a satisfactory explanation of the distant effects of 
heart disease, through embolism, in the brain, eye, lungs, kidneys, 
etc. Traube pointed out the mutual interdependence of the heart 
and kidneys. Subsequent studies have dealt more exclusively with 
the etiology of endocarditis. 



564 ENDOCARDITIS. 

Etiology. — Endocarditis is said to be primary and secondary. 
Regarding the primary disease, the same restrictions apply as in 
pericarditis. Cases become fewer every year where no outside cause 
can be discovered. It is safer, in the light of existing knowledge, to 
consider all cases secondary and as expressions, with the inflamma- 
tions of other serous membranes, of infection. Endocarditis, like 
pericarditis, may occur in the course or as a sequence of any disease 
that is produced by micro-organisms. The micro-organisms actually 
encountered in the study of lesions in the heart are chiefly those of 
pus and of pneumonia. During its prevalence as an epidemic, influ- 
enza may leave lesions in the heart. 

The disease presents itself under three distinct forms : simple, 
malignant, and sclerotic. The simple and malignant are acute forms, 
which result in the sclerotic as the chronic form. It was hoped 
that the simple might be distinguished from the malignant by the 
diseases with which these forms respectively were found associated. 
It is, however, admitted that these forms are variations rather of 
degree than kind, and that the simple may pass into the malignant 
form. It has always been admitted that the sclerotic is only a later 
stage of either of the acute forms. The hope thus entertained proved 
fallacious, as the same micro-organisms have been found in both 
forms. The simple form distinguishes itself more frequently by 
failure to show micro-organisms of any kind, the malignant form by 
the frequency of the micro-organisms of pus. Weichselbaum made 
bacteriological examinations of twenty-nine fatal cases of endocar- 
ditis. In eight cases of the simple form there were no micro-organ- 
isms in the deposits on the valves; seven showed the diplococcus of 
pneumonia, six the streptococcus, and two the staphylococcus; six 
showed other rare micro-organisms, the nature of all of which was 
not definitely established. One case showed three varieties. The 
relation of these bacteria to the disease was proven by the production 
of the disease in rabbits in all cases if the membrane had been pre- 
viously subjected to some mechanical injury. If the valves were 
healthy it was impossible to excite endocarditis; hence it is inferred 
that the disease is brought to the valves by the blood in the heart, as 
well as by the blood vessels of the heart. 

Morbid Anatomy. — Simple endocarditis is distinguished by the 
formation upon the valves of excrescences. The smooth, glistening 
serous membrane becomes opaque, thickened, and roughened, on ac- 
count of changes in nutrition and infiltration of small round cells. 
These roughened surfaces in their motion whip out from the blood 
fibrin, which comes to be deposited in the form of warty growths, to 
constitute the form commonly known as the verrucose. Particles 
from this cauliflower mass, dislodged from the surface of the valve, 



ENDOCARDITIS. 



565 



are swept onward by the current of blood to block vessels in the 
brain, lungs (infarction), spleen, kidneys, and the intestinal canal, 
with the development of characteristic signs. In certain cases de- 
structive changes occur in the fibrinous masses'. Xecrosis takes place. 
The tissue crumbles away to leave an ulcer whose surface is some- 
times covered with detritus or disorganized blood in the form of a 
membrane, to constitute the variety known as the ulcerative or 
diphtheritic form. These particles washed into the circulation ex- 
cite inflammation at their points of deposit, break down tissue in 
their vicinity, and form metastatic abscesses. The simple form is 
found in connection more especially with rheumatism (that is, rheu- 
matic polyarthritis) ; the malignant with septic diseases (puerperal 
fever, dysentery, scarlet fever, diphtheria, small-pox, the graver in- 
fections). Pneumonia may precede or develop either form. The 




Fig. 23?.— Endocarditis at and about the aortic valves, with ulceration, perforation of valves, 
and thrombi : a, aorta ; 6, pulmonary artery ; c, valve covered with vegetations ; d, perforation of 
a diseased valve ; e, ulceration of septum of the ventricles ; /, ulceration of ventricular surface of 
mitral valve. 

truth is, it is impossible to distinguish the form by the disease which 
causes the complication. The simplest rheumatism is at times at- 
tended or followed by the gravest endocarditis, so that, while it is 
true that in a general way the gravity of the infection determines 
the gravity of the complication, exceptions are frequent on both 
sides. 

Endocarditis of any form is most infrequent in connection with 
diphtheria and typhoid fever among the grave infections, but such 
simple diseases as mumps and quinsy may produce it. The endo- 
cardium may be affected in any part, but inflammation of the mem- 
brane which lines the body of the heart, unless ulcerative, is not 
likely to produce signs. The disease rarely exists upon the mural 
membrane alone, so that the term itself has come to indicate acute 



566 ENDOCARDITIS. 

inflammation of the valves. According to all observation the left 
side of the heart is much more frequently affected. Statistics from 
the Berlin Pathological Department, 300 cases, show the lesion in 
297 on the left side ; in 32 on the right ; confined to the left side 
alone, 268 ; and to the right side alone, but 3. The very reverse con- 
ditions prevail in the foetus and new-born child. Rauchfuss found 
192 cases of foetal endocarditis in the right side and but 15 in the 
left. The proportion may not be disputed ; the cases were derived 
from many sources. The mitral valve suffers most. Of the 300 
cases just mentioned, tabulated by Sperling, the disease was found 
255 times on the mitral, 129 on the aortic, 29 on the tricuspid, and 
3 on the pulmonary valves. The mitral valve was affected alone 
157 times ; the aortic valves alone 10 ; the tricuspid alone 3 times ; 
the valves of the pulmonary artery alone in not a single case. Em- 
boli occurred in one-fourth of the whole number of cases, and of 
these 81 cases deposits were found in the kidnej^s 57 times, the 
spleen 39 times, the brain 15 times, the liver and alimentary canal 5 
times each, and the skin 14 times. 

Either form of endocarditis may be accompanied by pericarditis, 
and is often associated also with affection of the substance of the 
heart itself (myocarditis). The simple form is most commonly 
found in connection with rheumatism. The relation of these dis- 
eases has been already discussed, with the frequency of complica- 
tion — ten to forty per cent, as given by various authors. As already 
stated, it is endocarditis which gives gravity to acute articular rheu- 
matism ; so that the patient, especially if the disease be very acute, 
is watched with solicitude throughout the course of the disease for 
the development of this affection. 

Symptoms. — Endocarditis sets in, as a rule, so insidiously that 
the period of its origin may escape notice. The fact that the patient 
experiences sensations of distress about the heart or shows irregu- 
larity of the pulse in the course of rheumatism does not necessarily 
indicate the development of the disease ; for any affection attended 
with fever, or more especially with pain, may show these signs. 
More continuous and persistent complaint of this kind, especially in 
the absence of much fever or pain, becomes more suspicious. Any 
interference with respiration, any cyanosis however slight, any 
visible pulsation of the veins of the neck, should call attention to the 
possibility of endocarditis. For the most part these signs are ab- 
sent. Careful observations of the temperature furnish reliable indi- 
cations. As a rule the temperature varies in correspondence with 
the affection of the joints, so that the existence of fever, in the ab- 
sence of sufficient joint affection to account for it, should lead to an 
examination of the heart. In the treatment of rheumatism the 



ENDOCARDITIS. 567 

temperature should be taken four times a day. With the devel- 
opment of endocarditis the heart becomes easily excitable. The 
lightest motion, sitting up in bed, any psychical emotion, excites 
the pulse. The hands and feet, the whole body, easily become 
cold on the slightest exposure. The patient complains of chilly 
sensations, shows goose flesh, tremor, and tendency to sweat. Ex- 
amination of the heart discloses excited action, increased area of 
impulse, dislocation of the apex, murmurs which substitute the nor- 
mal heart sounds. Diastolic murmurs are especially significant. 
With this association of symptoms the diagnosis is plain, and the oc- 
currence of these signs in the course of a simple rheumatism, light 
pneumonia, or other infection speaks for the existence of simple 
endocarditis. 

The septic form is more frequently announced with a chill or 
series of shivering fits, and with severe pains in the bones and 
joints, which latter sometimes swell to present the appearance of 
rheumatism independently of the general existence of this disease. 
With the chi^l and fever, which is irregular, is anorexia, mental 
hebetude, prostration. The disease now shows itself in one of two 
distinct forms, the septic or the typhoid. The septic form distin- 
guishes itself especially by the occurrence of repeated chills, at such 
intervals at times as to simulate and be mistaken for malarial fever, 
and more especially by profuse sweats. The chill, fever, and sweat 
are supposed to be due to metastases, which sometimes reveal them- 
selves by characteristic signs. The typhoid form shows benumbed 
sensorium, sopor, stupor, muttering delirium, along with a dry- 
coated tongue, sordes about the teeth, enlargement of the spleen, 
roseola, and diarrhoea. The disease is most frequently mistaken 
for typhoid fever. The temperature curve is not typical, as in a case 
of typhoid fever, but the fever is sustained at a high level for a 
period as long, so that the case, even if closely studied, may be re- 
garded as an anomalous typhoid. Endocarditis may be distinguished 
by examination of the heart, but then only when the heart shows 
distinctive signs, which is by no means always the case. Irregu- 
larities, palpitations, dyspnoea, more particularly more profound 
prostration, point to ulcerative endocarditis, especially when these 
signs occur in the course of a grave infection. Typhoid fever is 
a primary disease, ulcerative endocarditis is secondary, and the se- 
quence must often determine the character of the affection. 

Nothing constant may, therefore, be observed about the heart 
itself, so far as concerns its increase in size, disturbance of sound, or 
alteration of circulation. One thing only is constant, the weakness 
of its action. The pulse is more feeble, often more frequent, al- 
ways, as stated, more easily excited. Much of this alteration is due 



568 ENDOCARDITIS. 

to affection of the myocardium, which is usually involved in the 
malignant form of the disease. It must be recognized that septic en- 
docarditis can run its entire course without the development of 
metastases. When they occur they develop in the order of fre- 
quency mentioned above. The brain may be affected directly by the 
deposit of emboli, or functional disturbances of great gravity, but 
without demonstrable tissue lesions, may show themselves as in the 
course of grave acute infections. Suppurative meningitis may occur 
in connection with thrombus of brain sinuses. 

The field of vision may be contracted to absolute blindness by 
haemorrhage in the retina or embolic occlusion of the central artery. 
A septic embolus may develop panophthalmitis with destruction of 
the globe. Affection of one eye is soon followed by affection of the 
other, as a rule. Haemorrhages and emboli may also affect or de- 
stroy the hearing. 

The most characteristic changes take place in the skin. Minute 
haemorrhages, usually petechial, often excessively profuse, occur in 
the skin, with eruptions which simulate those of measles and scar- 
let fever, herpes and pemphigus, with sero-sanguineous contents. 
The same haemorrhages may occur also in the conjunctiva and cav- 
ity of the mouth. Swelling and pain in the joints have already been 
noticed. These accidents occur sometimes in consequence of tox- 
aemia, often as the result of embolism. The spleen is nearly al- 
ivays sivollen. It is this enlargement of the spleen which especially 
leads to confusion with typhoid fever. Infarctions in the kidneys 
develop albuminuria and bloody urine, which distinguishes itself 
more especially by its disappearance and recurrence. Occlusion of 
intestinal vessels reveals itself in colic, diarrhoea, and peritonitis. 
In the lungs there is bronchial catarrh, haemorrhage, pleurisy, oede- 
ma, and hypostasis sub finem vitae. 

The diagnosis rests upon the pre-existence of a primary cause. 
The disease must be distinguished, as stated, from typhoid fever and 
malaria, from tuberculosis and pneumonia, from the exanthemata 
and rheumatism. 

The prognosis is always grave. Nearly all cases of malignant 
endocarditis perish. The pericarditis is often the terminal link in 
the chain of "disease process. Occasionally recovery occurs even 
from a case of ulcerative endocarditis, though there is in these 
cases always room for doubt as to the accuracy of the diagnosis. 
The prognosis of simple endocarditis is grave, for the reason that a 
benign course is sometimes suddenly interrupted by an embolus in 
the brain, which may take life at once or more often produce a sud- 
den hemiplegia. Most of the hemiplegias in the young are due to 
this cause. Recovery with restitutio ad integrum is always possible 



SCLEKOTIC ENDOCARDITIS. 569 

in a case of benign endocarditis. All the signs, including the physi- 
cal signs, may have existed in marked degree and may disappear 
entirely. This happy conclusion is, however, the exception and not 
the rule. In the rule the lesion is organic. It persists, and the case 
is changed from the acute into the subacute or chronic sclerotic 
form. 

SCLEROTIC ENDOCARDITIS. 

It is estimated that about one-half of the cases of acute endocarditis 
become chronic, but sclerotic endocarditis begins often in such subacute 
form as to pass unrecognized, so that the disease develops insidiously. 
It is in these cases often only accidentally discovered. In the ma- 
jority of cases patients consult the physician in relief of symptoms 
which they themselves refer rather to disease of the lungs. In a 
respectable proportion of cases the intercurrence of some other affec- 
tion, especially of the lungs, bronchitis, pleurisy, pneumonia, etc., 
makes manifest a heart disease which has hitherto run a latent 
course. 

Chronic endocarditis is in its anatomy a sclerotic process. The 
smooth, pliable, semi-elastic tissue of the valves becomes indurated? 
stiffened, thickened; nodules form in beads along the free edge of 
the valves just within the border, at the point of closest contact, on 
the auriculo-ventricular valves, and about the corpora Arantiae on 
the semilunar valves, or chronic thickening of the endocardium 
which lines the walls of the heart binds down the chordae tendineae. 
Segments of valves are sometimes agglutinated or fastened to the 
sides of the heart or vessels into which they open. The tissue is 
thickened and stiffened by deposits of atheromatous matter. The 
valves are split or perforated by destruction of substance. From 
whatever cause, the lesion interferes sooner or later with the circula- 
tion of the blood, and in such a way as either to prevent the perfect 
closure of the valves and thus permit regurgitation, or to offer 
obstacle to the passage of blood and thus lead to obstruction. 

Lesions of the valves are thus divided into insufficiencies (regur- 
gitations) and stenoses (obstructions). While the final event is in all 
cases the same, the condition which immediately results varies greatly 
according to the nature of the lesions, and the prognosis of an indi- 
vidual case, other things being equal, rests largely upon the form of 
the disease. The difficulty, whatever be its nature, is overcome and 
counteracted for a time by increase in the force of the heart, due to 
hypertrophy of its muscular substance. In this regard the tissue of 
the ventricle has great advantage over that of the auricle. Most 
fortunate are those lesions whose difficulties can be overcome by 
hypertrophy of the ventricles. Such a hypertrophy is said to be 



570 



SCLEROTIC ENDOCARDITIS. 



compensatory. The condition is best illustrated by a comparison of 
the normal pulse curve with that of mitral regurgitation with per- 
fect compensation. It occurs rapidly in young people and remains in 
force long, so that the damage which is done to the heart becomes 
manifest only, as a rule, under extraordinary demands, as from great 
exertion, or more particularly from disease of the lungs. Sooner or 
later in all cases the hypertrophy must give way. Any case may be 
put, but no case can be kept, under ideal surroundings. Some acci- 




Fig. 238.— Sphygmographic tracing of normal pulse curve 
of resilience. 



p , elevation ; r, recoil ; e, elevation 



dent supervenes. Rheumatism recurs, some other infection develops, 
an atheromatous process extends to spread the disease over the valve 
affected or to implicate other valves. The muscular tissue suffers 
fatty change. The heart undergoes dilatation, and the general signs 
of heart failure soon appear. 

Diagnosis. — The recognition of the valve affected, and the 
nature of its lesion, is usually easily made. A knowledge of the 




Fig. 



-Pulse curve of mitral regurgitation with perfect compensation : r, recoil. 



course of the circulation of the blood in the heart and the cause of 
its sounds furnishes the basis of diagnosis. 

As already stated, the disease process, from whatever cause, endo- 
carditis or atheroma, confines itself largely to the left heart. It 
becomes necessary practically to distinguish between lesions of the 
mitral and aortic valves. With the retrograde changes that take 
place in heart failure under dilatation of the heart, signs of failure of 
the tricuspid valve are of the main importance. Heart failure is 
often first announced by insufficiency of the tricuspid valve. In de- 
termining the nature of a valvular lesion it is necessary to ascertain 



SCLEROTIC ENDOCARDITIS. 571 

(1) the diameters of the heart, (2) the alterations in its sounds. Of 
these two factors, by far the most important is the increase of size. 
Unfortunately this sign is the most difficult of detection. The size 
of the heart, as determined by percussion, depends so much upon its 
situation with reference to the overlying lung that considerable 
hypertrophy may remain unrecognized in life, to be revealed only on 
autopsy. Any marked enlargement of: the heart may, however, as 
a rule, be readily recognized. Alterations in sounds are more decep- 
tive. Failure to close valves, or the presentation of obstacles, neces- 
sarily changes the natural sounds of the heart. But these sounds are 




S D S D S D S 

Fig. 210.— Mitral regurgitation with systolic murmur at the apex. S, systole ; D, diastole. 

altered by so many other factors, irregular vibrations, roughnesses in 
the walls of vessels, alterations in the composition of the blood, etc. , 
as to make the so-called murmurs comparatively insignificant. The 
adventitious murmurs usually occur in connection with the contrac- 
tion of the ventricle, so that murmurs synchronous with the first 
sound of the heart do not mean as much as those which occur with 
the second sound, with the diastole. The sounds connected with the 
lesions of the auriculo-ventricular orifices are heard most distinctly 
at the apex. Sounds connected with the lesions of the semilunar 
valves of the aorta and pulmonary artery are most distinct at the 
base. It is not a question as to where the sounds may be heard, for 




s d s d s d s 

Fig. 241.— Mitral stenosis with diastolic— i.e., presystolic— bruit at the apex. 

they may be heard all over the chest and sometimes in the back. 
The question is, where are the sounds heard in greatest intensity? 
Practically the valves of the heart which demand study are, as stated, 
the mitral, the aortic, and the tricuspid, which in frequency of af- 
fection at the inception of the disease stand to each other in the rela- 
tion of twenty, ten, and one. 

Vierordt represents the various murmurs graphically as shown in 
Figs. 240-243. 

Mitral Regurgitation. — Lesions of the mitral valve are by far 
the most frequent, and the particular form of lesion is that which 
prevents closure and permits regurgitation. In this accident the 



572 SCLEROTIC ENDOCARDITIS. 

blood, which should be propelled from the ventricle through the 
aorta, finds its way, some of it, back into the left auricle, which is 
thus kept in a state of distention. The auricle undergoes what hyper- 
trophy it may. It is, however, thin and distensible, and speedily 
undergoes dilatation, so that it is never perfectly emptied. In conse- 
quence of this distention the pulmonary veins are overloaded. Blood 
is dammed back into the lungs, whose capillaries are kept in a state 
of ectasia. The pulmonary artery is, therefore, overfilled to such 
degree as to cause in its rebound a sharp accentuation of the pul- 
monary valve sound. To overcome this distention in the pulmonary 



s d s d s d s 

Fig. 242.— Aortic regurgitation with diastolic bruit at second right interspace. 

artery the right ventricle undergoes hypertrophy. It increases in 
size to such extent that the right border of the heart in a marked 
case reaches over to and beyond the right border of the sternum. 

The recognition of mitral regurgitation rests, therefore, upon the 
following facts : 1. Dilatation of the left auricle, which may some- 
times be recognized by percussion dulness to the left of the sternum 
at the second rib. 2. Ectasia? of the capillaries in the lungs, with 
overdistention of the pulmonary artery and accentuation of the pul- 
monary valve sound, manifest to auscultation at the left of the ster- 
num at the second interspace. 3. f Increase in the transverse dia- 
meter of the heart, as determined by percussion dulness extending 




S D S D S D S 

Fig. 243.— Aortic stenosis with systolic bruit at second right interspace. 

often to the right border of the sternum. 4. Bruit, heard in greatest 
intensity at the apex and synchronous with the first sound of the heart. 
5. As a result of the hypertrophy of the right ventricle, dislocation of 
the apex to the left. The apex beat may be perceived in the mam- 
mary line or between it and the axillary line. The hypertrophy of 
the right ventricle compensates for the regurgitation for a long time, 
so that this lesion is looked upon as the most favorable of all the 
valvular affections. Patients with proper surroundings may live to 
die of old age. 

Mitral Stenosis. — The mitral valve is now so affected as to offer 
obstacle to the passage of blood from the left auricle to the left ven- 



SCLEROTIC ENDOCARDITIS. 573 

tricle. In mitral stenosis the blood received from the pulmonary 
veins accumulates in the left auricle. Much of it falls by gravity 
through the auriculo- ventricular orifice into the left ventricle. Ob- 
stacle is offered, as a rule, to the emptying of the auricle in its firmer 
final contraction. The bru it is therefore presystolic. The ventricle 
receives less than the normal amount of blood. The left auricle 
is distended earlier and more completely. There is consequently 
quicker and greater distention in the lungs and in the pulmonary 
artery. The resistance to the column of blood in the pulmonary 
artery is so great as to intensify and often delay the closure of 
the pulmonary valves. This sound is therefore accentuated early. 
The delay is at times so great as to separate its sound from that of 
the aortic valve and thus to split the second sound. In a marked 
case, at the height of the disease there is thus heard over the base 
a double click. The hypertrophy which takes place in the right 
ventricle produces the same changes in the heart as in the case of 
mitral regurgitation. Under the still greater pressure which exists 
in this instance, the heart muscle more speedily gives way and signs 




Fig. 214.— Pulse curve in mitral stenosis with broken compensation; feeble ascent, feeble force: 
e, elevation; r, recoil. 

of general stagnation more quickly supervene. The lesion of mi- 
tral stenosis is therefore much more grave. The average duration 
of life ranges about five years. The condition is aggravated by the 
fact that mitral stenosis almost never exists alone. The lesion which 
causes the stenosis is so disposed as to prevent closure. Regurgita- 
tion exists alone, as a rule. Stenosis alone is an exception. 

Aortic Insufficiency is usually due, as stated, to atheroma, a 
process which begins at the arch of the aorta and extends down to 
involve the valve at its base. This disease is therefore found much 
more frequently in age, though successive attacks of rheumatism or 
other infection may subsequently implicate also the aortic valve. In- 
sufficient closure of the aortic valve permits the reflux of blood from 
the aorta into the left ventricle. This reflux is immediately propelled 
under the powerful contraction of the ventricle, and the ventricle 
thereby undergoes a degree of hypertrophy ivhich is not approach- 
ed in any other form of heart disease. These are the cases of 



574 



SCLEROTIC ENDOCARDITIS. 



cor bovinum, where the heart is often quadrupled in its size and 
may weigh as much as three pounds. This extraordinary hyper- 
trophy of the left ventricle compensates for a time for a defi- 
ciency in the blood supply. The condition is recognized by in- 
crease in the size of the heart, more particularly in the vertical 



^ 



b, 




Fig. 245.— Hypertrophy of the left ventricle from insufficiency and stenosis of the aortic valves: 
a, left, 6, right ventricle; cross section (Ziegler). 

diameter, by a bruit which is heard in greatest intensity at the 
base and synchronous ivith the dilatation of the ventricle — that 
is, with the second sound of the heart. The force of the ventricular 
contraction propels the blood with violence into the branches of the 
aorta, so that the pulsations of the carotids are visible in the neck. 




Fig. 246.— Pulse curve in aortic regurgitation. 
Cannon-ball pulse. 



High, perpendicular ascent; sudden descent. 



In consequence of the regurgitation, the blood in the suddenly dis- 
tended arteries escapes rapidly in both directions, forward into the 
capillaries, backward into the heart, so that the vessels undergo a 
collapse as sudden as the distention. The rapid relaxation of the 
vessels gives rise to what is known as the cannon-ball or water- 



SCLEROTIC ENDOCARDITIS. 575 

hammer pulse — the " pouls du Corrigan" it was named in France, 
in honor of the Irish clinician who first described it. The sudden 
distention and collapse develops also tones in the great vessels, and 
bruits may be heard in the femoral, brachial, and carotid arteries. 
Pulsation is also propagated into the arterioles. The undulations 
are visible in the retina. The beds of the nails flush and blanch. 
Cerebral symptoms — vertigo or syncope — are not infrequent. 

Aortic Stenosis is more rare. Obstacle is offered at times by 
agglutinations of segments of the valves, more frequently by such 
thickenings or adhesions as to prevent apposition of the valve with 
the wall of the vessel. The ventricle is kept overdistended with 
blood, and in its contraction forces the blood through the narrowed 
orifice. The hypertrophy leads to increase in the diameters of 
the heart, more especially in the vertical direction. Auscul- 
tation reveals a bruit heard in greatest intensity at the base in the 
second right interspace and synchronous with the first sound of 
the heart. The pulse in these cases is hard and wiry. The 




Fig 247.— Pulse curve in aortic stenosis : short ascent, great resistance. Wire pulse. 

condition is usually associated with atheroma, which implicates also 
the vessels of the brain, and headache and cerebral haemorrhages are 
frequent complications. Aortic stenosis also seldom exists alone. It 
is usually associated with aortic regurgitation. Lesions of the aortic 
valve are, as a rule, more grave than corresponding affections of the 
mitral valve, chiefly because they more distinctly interfere with the 
blood supply of the brain and body, but largely on account of the 
conditions which create them — alcoholism, B right's disease, age, etc. 
— which also cause disease elsewhere. 

Tricuspid Insufficiency. — So long as compensation continues 
the patient may suffer no special distress. In consequence of over- 
exertion or intercurrent disease, sooner or later this compensation 
must give way. Dilatation supervenes and shows itself generally 
first in the right ventricle, which dilates to such degree that the 
tricuspid valve may no longer close the auriculo-ventricular orifice. 
This valve is said then to show relative insufficiency. The condi- 
tion is revealed by regurgitation into the right auricle, into the venae 
cavae and jugular veins. So long as the distention of the jugulars 



57G SCLEROTIC ENDOCARDITIS. 

is not too great the pulsation is seen only in the bulbs, which pro- 
trude at times like the small end of eggs at the root of the neck. 
Sooner or later the valves of the veins themselves become relatively 
incompetent and the undulation is transmitted along the whole 
course of the vessels in the neck. The same regurgitant wave is 
transmitted downward into the inferior venae cavse, and may be felt 
as pulsations of the liver by the hands apposed upon its surface 
and inserted under the edge of the ribs. Pulsation becomes distinctly 
palpable and visible also at the epigastrium, where a loud, blowing 
murmur, synchronous ivith the systole, may now be heard. Signs 
of general stasis now soon supervene. Dropsy begins to show itself 
about the feet as oedema of the ankles. It disappears during the 
night, to recur during the following day. The dropsy accumulates 
to mount up the lower extremities, invade the abdomen and serous 
sacs or subcutaneous connective tissue over the body, to constitute a 
genera] anasarca or sometimes to terminate life by oedema of the lungs. 

Interference with the circulation in the lungs is revealed by 
cough ; more especially by shortness of breath, which is one of 
the first signs of a flagging heart ; sometimes, more exceptionally, 
by hcemorrhage. 

The prognosis is grave in all cases. The lesion is organic and 
irremediable. The future of the case depends largely upon its sur- 
roundings. The life must be remodelled upon a new basis which 
would include peace of mind as well as rest of body. Attention 
must be paid to details, as to diet, clothing, exposure, habits of life, 
whereby idleness is to be avoided as much as excess. 

Tricuspid stenosis is congenital and is very rare. It is marked 
by presystolic murmur, most intense at the ensiform cartilage, ex- 
treme dilatation of the right auricle, and extreme stasis in the whole 
venous system. 

Pulmonary regurgitation, also congenital and rare, is marked 
by hypertrophy and dilatation of the right ventricle, with diastolic 
bruit at the base, second left interspace. 

Pulmonary stenosis, the most common congenital lesion of the 
heart, coincides often with a patulous foramen ovale, defects in the 
ventricular septum, and other malformations. It is marked by cya- 
nosis — " blue births " — the face and fingers are livid, the ends of the 
fingers clubbed; development is arrested; attacks of dyspnoea, ver- 
tigo, syncope are more or less continuous. Nevertheless life may be 
prolonged at times up to five, ten/or at the outside limit fifteen years. 
It is often cut short by tuberculosis. 

The physical signs are : an intense bruit, most audible at the 
second left interspace, synchronous with the systole, and extreme hy- I 
pertrophy or dilatation of the right ventricle. 



SCLEROTIC ENDOCARDITIS. 577 

Treatment. — So long as compensation exists the case calls for no 
treatment. Compensation may be, in the young, at times excessive, 
when it may be subdued by occasional doses of the bromides, gr. 
xx. -xxx. in half a glass of water every two to four hours. The 
same remedy or a small dose of chloral gr. v. at bedtime, or tri- 
onal gr. xv. in a cup of hot milk after supper, may secure sleep 
and allay nervousness. The salicylates should be prescribed at first 
in acute cases or exacerbations, in address to the cause. The mildest 
of the antip3 T retics, phenacetin, may relieve an obstinate headache. 
Violent action of more continuous character is best subdued by the 
application of an ice bag to the chest. Hollow tin vessels filled with 
cold water, in the form of shields, may be worn during the day. 

With the first sign of failure — shortness of breath, dropsy, or cya- 
nosis — resort must be had at once to the cardiac stimulants. The 
evil day may be postponed for a time by the judicious use of alcohol; 
a dessert- to a tablespoonf ul or two of good whiskey once or twice in 
the twenty-four hours may suffice. Sooner or later recourse must 
be had to digitalis. Mild effects may be had with the use of the 
tincture in doses of five to fifteen drops every three to six hours. 
More prompt and powerful effect may be secured by the use of the 
infusion made fresh from the leaves, a teaspoonful, a dessertspoon- 
ful, or a tablespoonful every two to four or six hours. Digitalis re- 
mains the most powerful cardiac stimulant. It has the advantage 
that its action may be sustained. It has the disadvantage that it acts 
slowly and that in large doses it irritates the stomach. It should 
never be given uninterruptedly. Its administration should cease so 
soon as its effect upon the pulse is made manifest, for fear of pro- 
ducing tetanic contraction. Unfortunately digitalis not only stimu- 
lates the ventricle but also raises the tension of the capillaries, which 
therefore, to some degree, resist the action of the heart. A great 
desideratum was a remedj- which would increase the tension of the 
ventricle and lessen that of the arteries. Such a remedy was found 
in nitroglycerin. This remedy has the additional advantage that it 
acts at once. It may be used, to bridge a collapse, in dose of one to two 
drops in whiskey and water every two to six hours. In imminent 
danger the drug may be used subcutaneously. It shows its best 
effects in arterio-capillary sclerosis and defective action of the kid- 
neys. Stasis of the blood in the kidney leads to most disastrous con- 
sequences; the secretion of the kidney maybe released at once under 
the action of nitroglycerin. Strychnia, one-per-cent solution, begin- 
ning with one drop and gradual!}- increasing, is the remedy par excel- 
lence for continuous sustentation of the heart. Dropsy is best relieved 
by calomel. No remedy in the materia medica has the efficacy of calo- 
mel in the dropsy of heart disease. It must be given in doses of 
37 



578 MYOCARDITIS. 

three grains three times a day, and no effect must be looked for be- 
fore the administration of the seventh to the ninth dose. Any irri- 
tant effect upon the bowels may be restrained by opium, and ptyal- 
ism avoided by the use of chlorate of potash, cleansing the mouth 
and touching ulcers with caustic (chromic acid). Excessive dropsy 
may demand puncture of the legs, best with two or four clean silver 
canulas, rendered aseptic by boiling five minutes with the carbonate 
of soda, five per cent. Further details of treatment under Heart 
Failure. 

MYOCARDITIS. 

Myocarditis (j*v$, muscle). — Inflammation (infection) of the sub- 
stance (muscle) of the heart. 

Etiology. — Myocarditis results from the same causes as peri- and 
endocarditis and presents itself in the same forms, acute and chronic. 
Infection is conveyed to the myocardium directly through the coro- 
nary arteries or indirectly through the endocardium or pericardium. 
Myocarditis may occur, therefore, in the course of any of the infec- 
tions, and is always present in some degree in connection with both 
pericarditis and endocarditis. The micro-organisms which most fre- 
quently produce myocarditis are the streptococci and staphylococci 
of pus. When these organisms are introduced directly into the cir- 
culation, as in the experiments of Ribbert with fragments of potato 
containing pure cultures, myocarditis occurred more frequently than 
inflammation of the membranes of the heart. So myocarditis oc- 
curs, as a rule, in the course of septico-pyaemia. Rheumatism shows 
preference for the membranes, diphtheria for the walls, of the heart. 
Interstitial myocarditis — i.e., round-cell infiltration — always occurs 
in the course of diphtheria, scarlet fever, and typhoid fever. 

Morbid Anatomy. — The infection may result in the disintegra- 
tion of muscular tissue and the formation of abscesses, or in inter- 
stitial inflammation with the development of scleroses, scars, or, in 
consequence of weakening, aneurismal dilatation and rupture. 

Symptoms. — The disease is rarely found alone. It occurs in con- 
nection with endocarditis and pericarditis, whose symptoms over- 
shadow the lesion of the heart. Myocarditis may be suspected in 
the presence of the general symptoms of heart disease — palpitation, 
dyspnoea, dilatation, heart failure, and syncope — in the absence of 
unmistakable signs of endo- and pericarditis. The dyspnoea of myo- 
carditis is often peculiar. It commonly occurs suddenly in the first 
hours of the night, and announces itself with the anxiety and distress 
of asthma. It is known, therefore, as cardiac asthma, and is distin- 
guished from true asthma by the fact that it occurs in later life in 
connection with other signs of heart disease. 



HEART FAILURE. 579 

The diagnosis, independent of affections of the membranes, is 
often difficult, sometimes impossible. Myocarditis is commonly an- 
nounced by a preliminary period of arhythmia marked by periodical 
acceleration due to direct change in the muscular tissue. 

The treatment is symptomatic and does not differ from that of 
affection of the membranes. 

HEART FAILURE. 

Heart failure from diffuse degeneration (myocarditis) occurs ulti- 
mately in all kinds of organic heart disease, and is the immediate 
cause of death in all the chronic processes. The degeneration is pa- 
renchymatous and is chiefly fatty. The striae grow dim on account 
of transformation into fat, which appears in granules ; more rarely 
the degeneration is into waxy and amyloid matter. The heart mus- 
cle loses color, becomes yellowish, greenish, or mottled, loses firm- 
ness, becomes friable and fragile. 

Etiology. — The process is usually secondary to valvular disease, 
in the course of which occurs, first, hypertrophy, then dilatation with 
degeneration, along with disturbance of compensation. It sets in 
also in all cases marked by the same sequence, as in the course of 
emphysema, long-continued, frequent asthma, chronic bronchitis, in 
obstruction to the circulation outside of the heart. It occurs also in 
the left ventricle in Bright's disease, aneurism of the aorta, arterio- 
sclerosis, processes which lead to heart failure through hypertro- 
phy, dilatation, and degeneration. Affection of the membranes 
which cover and line the heart involves zones of subjacent tissue by 
direct contiguity of structure. Diffuse degeneration sets in also in 
consequence of insufficient nutrition, from impoverished blood — as in 
continued haemorrhage, the various forms of anaemia— from disease 
of the coronar}^ arteries, and from general chronic disease, tubercu- 
losis, cancer, marked by marasmus. t Acute failures are observed 
most frequently in consequence of the infections, as the result of the 
direct effect of toxines. Gradual and sudden failures occur in alco- 
holism. Alcohol is a whip to the heart, which responds as long as 
may be, but finally breaks down. The heart is always weak in 
drinkers. It becomes too weak to perform the extra work imposed 
by disease or effort, or to respond finally even to extra stimulus. 
Hence the great mortality of drunkards. Depressing mental emo- 
tions, anxiety, finally weaken the heart, until it may actually break 
under a sudden strain — an accident which never happens in sound 
j muscle. Severe or prolonged physical effort, heavy labor, as that of 
I porters, smiths, etc., exhausting discharges, have eventually the same 
I effect. There is no lack of causes to explain the insidious process. 
The symptoms are almost wholly subjective and depend upon 



5S0 HEART FAILURE. 

the retardation of circulation and stasis. There is a feeling of grow- 
ing weakness, loss of general energy. The lightest effort excites the 
heart and quickens the breath — conditions which may be noticed first 
in climbing stairs or in sudden emotional disturbance. (Edema oc- 
curs about the ankles at night, disappears in the recumbent posture, 
and gradually increases in amount during the day. A sense of ful- 
ness is felt in the region of the liver. The patient takes cold upon 
the slightest exposure : begins to cough ; the face becomes florid or 
pale : the mind is more sluggish or anxious ; there is loss of energy, 
of the power of concentration, and of clearness. Later dropsy be- 
comes marked, cyanosis develops with orthopnoea, cardiac asthma, 
delirium cordis. 

The physical signs, aside from the evidence of valvular disease, 
are not distinct. Durness may be appreciated beyond the natural 
boundaries, especially to the right of the sternum. The apex ma}" 
be displaced, especially to the left, in consequence of dilatation of the 
left ventricle. Aside from the irregular and tumultuous actions that 
betoken exhaustion, the heart sounds are muffled. Aside from the 
sounds of valve disease, murmurs may be heard, usually systolic, in 
consequence of relative insufficiency of the mitral or tricuspid valves. 
The diagnosis is not difficult. The important question concerns 
the cause, whether disease of the heart, toxaemia, anaemia, alco- 
holism, obesity, etc. The neuroses of the heart are separated by 
the absence of physical signs and evidences of general stasis. 

Treatment must address itself to the cause, in relief of rheuma- 
tism, art erio- sclerosis, anaemia, haemorrhage, obesity, alcoholism, 
overwork, etc. Patients affected with emphysema, asthma, and 
chronic bronchitis may learn to spare the heart extra effort, avoid- 
ing at the same time that extreme inactivity which conduces to de- 
generation and hypertrophy from disuse. Every imprudence in diet 
is quickly punished. The meals must be regular and the patient 
must be abstemious. The food should consist chiefly of fruit and 
fish and the white meat of fowl. All vegetables, except potatoes 
baked whole, should be avoided. A glass of warm water, at most a 
cup of very weak tea, is a sufficient supper. An exclusive milk diet 
will itself sometimes cause oedema and dropsy to disappear. Any 
overfeeding is hurtful. The exercise must be graded to the in- 
dividual case. Nothing is worse than actual indolence, except over- 
work. Climbing stairs is always hurtful, but climbing hills in the 
open air is helpful if practised aright. Fresh air feeds, and exercise 
tones, the muscle of the heart. Much can be accomplished by a 
change of climate, especially by sojourn at watering places — in 
Germany. Marienbad, Xauheim ; in our own country, the Virginia 
Springs — with exact regulation of the diet and exercise. Damage is 



NEUROSES OF THE HEART. 581 

often done by incautious exercise, as with the Oert el method (Schott). 
For steady support no remedy equals strychnia. Sooner or later the 
necessity arises for the administration of the various stimulants, at 
the head of which is digitalis. Many cases recover absolutely under 
the judicious use of digitalis, which may be administered in tinc- 
ture, gtt. v.-x. two or three times a day : fresh infusion, a teaspoon- 
ful or two ; or powder of the leaves, gr. i.-iij. with sugar of milk at 
the same interval. Strophanthus, tincture, gtt. xv.-xl., makes a good 
temporary substitute. Sudden heart failure calls for more powerful 
stimulants — alcohol, ether, camphor. Thus camphor may be dis- 
solved in ether 1 : 10, and of the mixture ten drops may be adminis- 
tered every fifteen minutes or half-hour, or for still quicker effect be 
injected subcutaneously. Further details are described under the 
treatment of valve lesions. 

TUBERCULOSIS OF THE HEART. 

Tuberculosis of the heart is very rare. Deposit is sometimes 
found in miliary tuberculosis under the endocardium of the right 
ventricle. Tuberculosis is more frequent in connection with chronic 
pericarditis. 

SYPHILIS OF THE HEART. 

Syphilis of the heart is extremely rare. Most of the lesions so 
interpreted are cicatrices of arterio-sclerosis. Specific indurations of 
muscle are sometimes found in connection with inherited or acquired 
syphilis, and gummatous deposits, sometimes caseous, have been 
found in the walls of the heart and have broken through into its 
cavities. Occasional cases of arhythmia, palpitation, etc., otherwise 
defiant, are cured by appeal to antisyphilitic treatment, as suggested 
by some accidental finding elsewhere in the body. 

CYSTICERCUS. 

Cysticercus, echinococcus, may come to lodge in the heart muscle, 
and, after rupture into its interior, have been disseminated to the 
lungs or elsewhere over the body. 

All these conditions are suspected or recognized by coexistent 
evidence of disease elsewhere outside of the heart. 

NEUROSES OF THE HEART. 

The heart muscle may contract and expand — that is, perform its 
work — entirely independently of the nervous system. The heart 
muscle may not only contract and expand, but it may do these 
things rhythmically without nerves. What is muscular tissue, any- 
how, but the terminal expansion of nerve fibre ? In the body, how- 



582 PALPITATION. 

ever, the heart muscle moves in obedience to nerve stimulus, which 
excites it or retards it, as Lauder Brunton says, as the whip, the 
reins, and the brake regulate the movements of the horse and cart. 

The mechanism of the nerve supply to the heart, notwithstand- 
ing the study which has been expended upon it, is not yet definitely 
established. Three sets of nerves, the vagus, the sympathetic, and 
the vaso-motors, have to do with the motions and sensations of the 
heart, to say nothing of the ganglionic masses embedded in its 
substance. Recent studies prove that the ganglia belong exclusively 
to the auricles — i.e., the receiving chambers— and that they are con- 
nected exclusively with the sensitive sphere. The ventricles have 
no ganglia. 

The pathology of the nervous affections is even less satisfac- 
tory than the physiology, and the neuroses of the heart are studied 
wholly from the standpoint of symptomatology. It is observed 
that the heart, so far as motor nerves are concerned, is increased 
or decreased in the frequency and force of its action, or has its 
rhythm interrupted, and that regarding the sensory nerves there is 
distress, anxiety, and positive pain. Disturbances of the motor sys- 
tem are generally summed under the most obtrusive symptom, pal- 
pitation, as disturbances of the stomach are summed under the term 
dyspepsia. Neither of these affections is in any sense a disease, but 
a symptom of many diseases inside and outside the heart. Con- 
tinued acceleration and protracted retardation are often characterized 
as Tachycardia (ro^us, quick) and Bradycardia (fipadvs, slow). 

PALPITATION. 

Palpitation arises, first, in connection with disease of the heart 
itself. Affections of the valves, of the substance of the heart, of 
the pericardium, are all sooner or later attended with palpitation. 
These conditions are excluded from consideration with the neuroses. 
The causes of motor disturbances are summed under the heads or di- 
visions, mechanical, chemical, and reflex. 

1. That overloading of the whole vascular system which occurs 
immediately after a full meal is often attended by palpitation. Any 
affection of contiguous viscera, as by accumulation of fluid in the 
pleural sac; affections of the lung substance itself which may disturb 
the position of the heart or interfere with the egress of blood from 
the heart; more especially from distention of the stomach, as from 
gas, act in a mechanical way. Palpitation of the heart has been 
noticed among the frequent symptoms of gastric catarrh and dys- 
pepsia.. These conditions present often coldness of the surface and 
extremities, pallor, precordial pain, attacks of syncope, as the result 
of pressure partly, and partl}^ of absorption of toxic gases. A mode 



PALPITATION. 



583 



of taking life in old times consisted in the deglutition of large quan- 
tities of fresh blood, the coagulation of which made a solid mass in 
the distended stomach to interfere with or absolutely arrest the ac- 
tion of the heart. Gaseous distentions of the intestines, especially of 
the transverse colon, act in the same way. The shock which shows 
itself, early in those enormous accumulations which occur in the 
course of obstruction of the intestine and after perforations is partly 
due to this cause. 

2. The most frequent causes of palpitation of the heart are the 
chemical causes, at the head of which stands poisoning by nicotine. 
Tobacco smokers form a large contin- 
gent of cases of heart neuroses. When 
the disturbance shall have once oc- 
curred as a result of the excessive use 
of tobacco, even a moderate use will 
suffice to keep it up, so that a cure may 
follow only entire abandonment of use. 
Tea, coffee, alcohol in excess, or espe- 
cially in impure forms, act in the same 
way. Mention has been made already 
of the effects of toxic gases in the ali- 
mentary canal. 

3. Keflex causes are numerous. 
They include also dyspeptic states, 
disease of the kidney, of the uterus and 
its adnexa, and any outside irritant. 
A patient in the experience of the 
author was often awakened in the 
night with chilly sensations, extreme 
anxiety, cold sweat, and violent, tu- 
multuous palpitation. The cause was 
finally discovered in a subacute prosta- 
titis with posterior urethritis, and the symptoms all subsided under 
injections, by means of the Ultzmann catheter, of strong solutions of 
nitrate of silver. 

Besides all these things, the heart may be excited by causes of 
emotional nature and by alterations of the blood, as in chlorosis, 
anaemia, and exhaustions. So it may be seen that most of the cases 
of disturbance arise from causes outside the heart. Sometimes the 
relation between cause and effect may be distinctly traced, as after 
smoking, the use of alcohol, heavy meals, tea drinking, etc. Often 
it must be searched for in some disease of remoter organ. Tachycar- 
dia and bradycardia may be due to irritation of the abdominal sym- 
pathetic (Eccles, Riegel). The practitioner may not overlook the 
possibility of epileptic basis (Talamon). 




Fig. 2 i 8.— Topography of the heart. 
Mechanical relation of the heart and 
abdominal aorta to the stomach and 
contiguous viscera. 



584 PALPITATION. 

Symptoms. — Palpitation is defined as pulsations that are per- 
ceived by the patient. It comes on in paroxysms with intervals of 
more or less complete freedom from attack. The paroxysms may oc- 
cur at any hour of the day or night. The attacks which occur at night 
in bed and arouse the individual from sleep are mostly due to disease 
of the heart itself. The heart begins to beat violently. It pounds 
against the walls of the chest. The vessels may throb in the neck. 
The eyes become suffused and the head aches. As a rule the palpi- 
tations of the heart are more frequent than the pulsations. All the 
actions of the heart do not affect the pulse. The heart beats with 
the foetal gallop ; or, on the other hand, it may be very rapid and very 
feeble, so that the pulse may consist of a series of rapid, almost im- 
palpable waves. As Jimenez puts it, it has the rapid vibrations of 
a loose string. On the other hand, the beatings of the heart may 
be so feeble as to be scarcely felt by the patient, and these cases cre- 
ate the most alarm. Patients say so long as the heart beats they 
have no fear; it is only when it seems to stop beating that they be- 
come frightened. The pulse in these cases is very feeble, sometimes 
hardly perceptible. The surface is cold, the expression anxious. 
Sometimes there is actual syncope. The attack passes off, as a rule, 
in from half an hour to an hour or more. The more protracted cases 
are found especially in neurotic or hysterical subjects. The precor- 
dial distress and anxiety disappear, the surface becomes warm and 
the mind tranquil. These attacks may recur several times in the 
course of the day or at indefinite intervals, with or without connec- 
tion with distinct exciting cause. 

The prognosis depends entirely upon the cause. Organic disease 
must be eliminated, affections of remote organs discovered. 

The treatment will address itself wholly to the cause. In im- 
mediate relief of attack nothing is so good, as a rule, as the applica- 
tion of cold, which may be applied with an ice-water bag, or, better, 
with the light Leiter's coil. A small dose of chloral gr. v.-x., with 
a teaspoonful or two of whiskey, is justifiable in a bad case. A bro- 
mide, gr. xxx. largely diluted, will often suffice. Dyspeptic cases 
may be often cured by hydrochloric acid gtt. x. before meals, or by 
arsenic gtt. iij. after meals. Nervous patients are relieved with the 
use of valerian, one drachm of the tincture in a tablespoonful of 
water every fifteen minutes or half an hour. A teaspoonful or two 
of the tincture of camphor diluted, a pill of asafcetida, the natro- 
benzoate of caffeine gr. iij. every three hours, the more continuous 
use of small doses, gtt. ij.-v., of the tincture of digitalis or the tinc- 
ture of strophanthus, with regulation of the habits and removal of the 
cause, may cure the condition. Too rapid action (tachycardia) may 
necessitate the use of morphia; too slow action (bradycardia), of atro- 



ANGINA PECTORIS. 585 

pia to allay irritation of the vagus from constriction at the aortic 
valves (Rummo). 

ANGINA PECTORIS. 

Much more serious are the cases of sensory disturbance, because 
they depend, as a rule, upon organic disease. In these cases a sense 
of constriction of the chest assumes prominence over all other symp- 
toms ; hence the disease is called angina pectoris. Angina pectoris 
is not, however, strictly speaking, a neurosis of the heart. A true 
case of angina depends upon disease about the aortic valves, and the 
disease is of such a nature as to offer obstacle to the escape of blood 
(stenocardia) ; hence angina pectoris occurs more especially in indi- 
viduals of advanced life, from forty to seventy, and in connection 
with atheroma and arterio-sclerosis. Obstacle offered to the es- 
cape of fluid from other hollow viscus — e.g., the bladder — as well as 
the heart, causes pain. Distention of the left ventricle is attended 
also with a sense of anxiety and danger like that of impending death. 
Fortunately angina pectoris is a very rare disease. Pseudo-anginas^ 
neuralgias of the heart which simulate the genuine affection, are very 
common and are very often mistaken for angina pectoris. 

Symptoms. — Angina pectoris distinguishes itself especially by 
pain, and by pain which is best described as agonizing. The pain 
seizes the patient suddenly during the day or night. It arises in the 
prsecordium and radiates thence to the left shoulder and dozen 
the left arm. It may shoot back toward the spine or scapula, in 
rare cases downward, but the tract described is its usual course. 
The pain literally transfixes the patient. He lies motionless as if 
paralyzed. The face shows the picture of terror; it is deathly white 
or livid; cold sweat beads the surface. The patient may succumb 
at once in individual attack. Usually the pain subsides in the course 
of a few minutes, to leave the patient in a state of profound prostra- 
tion with intense apprehension of subsequent attack. 

Diagnosis. — Pseudo-anginas are much less severe. The patient 
in these cases is able to move about and may adopt various positions 
or resort to pressure in the attempt to secure relief. Pseudo-anginas 
occur more particularly in neurotic and hysterical patients, conse- 
quently much more frequently in the young and in the female sex. 
They are found in connection with other neuroses, with anomalies of 
menstruation, etc. Pseudo-angina is a simple neuralgia, in connec- 
tion commonly with anaemia, neurasthenia, hysteria, or hyper chon- 
driasis. The individual paroxysm may in these cases last for hours. 
The diagnosis of true angina rests upon the age of the patient and 
the sex — the great majority of cases occur in males — as well as upon 
the recognition of the heart lesion by physical signs. 



586 EXOPHTHALMIC GOITRE. 

The prognosis is extremely grave. Any attack may be fatal. 
Yet patients may survive many years. 

In treatment the most effective remedy is the nitrite of amyl, 
which, in the smallest dose, has remarkable effect upon involuntary 
muscle fibre, especially that of the heart. It is used by inhalation of 
three to five drops from a handkerchief. Victims of this disease 
learn to carry with them "pearls" containing drops of this drug, which 
they may crush between the fingers upon a handkerchief and use im- 
mediately. With the flushing of the face, which occurs at once from 
relaxation of the capillaries and emptying of the heart, the pa.tient 
usually gets relief. Sometimes it fails, when resort must be had at 
once to ether or chloroform. Nitroglycerin, gtt. i.-iij. every four 
hours, may later sustain the action of the nitrites. A milder attack, 
especially if attended by some signs which the patient from his own 
experience may consider premonitory, may be cut off or cut short 
by a dose of morphia or chloral. Arsenic and iodine (Fowler's solu- 
tion and the iodides) are mainly relied upon in the treatment of the 
intervals. It goes without saying that the victims of this disease 
must in every way lead model lives. 

EXOPHTHALMIC GOITRE. 

The curious association of symptoms on the part of organs as re- 
mote from each other as the heart, the thyroid gland, and the eye, 
was first pointed out by Basedow (1840), and was described a few 
years later by Graves, of Dublin, and hence is called in Germany 
Basedow's, and in English-speaking countries Graves', disease. The 
connection of goitre and palpitation had really been first observed by 
Flajani, of Rome, in 1802 ; the Italians still call it the morbo di 
Flajani. Parry (1825) first noticed also the exophthalmos. 

The affection is not common, but is noticed much more fre- 
quently in women, especially in states of exhaustion, as after rapid 
child-bearing, prolonged lactation, exhausting discharges, domestic 
infelicities, etc. Typical cases occur in men, usually without dis- 
coverable cause. The disease shows itself, as a rule, between 
puberty and maturity. It is seldom seen in advanced life, if only 
because the disease, while not exactly fatal, cuts short the duration 
of life. 

Symptoms. — Usually the first symptom to attract attention is 
palpitation of the heart, frequently in the form of tachycardia. As 
the disease is often associated with altered conditions of the blood or 
nervous distress, the palpitation is attributed to these causes, and, 
being but paroxysmal, is overlooked. A little later the attacks be- 
come more common and more continuous. The heart becomes 
excitable; the slightest emotional disturbance or physical effort 



EXOPHTHALMIC GOITRE. 



5S7 



precipitates palpitation ; the patient becomes more and more emo- 
tional. At this time is noticed also — it may have been remarked 
before— fine tremor of the muscles, especially of the hands. The 
symptom is not obstrusive, and is usually brought out only upon 
interrogation. The patient recalls the fact that the condition has 
existed for many months. The tremor and palpitation may continue 
for months or for the greater part of a year before the occurrence of 
other signs. Next there is usually observed some enlargement of 
the thyroid gland. The mode of dress makes a woman sensitive to 
deformity or alterations about the neck, so that this condition is soon 
remarked. One or the other lobe of the thyroid swells ; very soon 





Fig. 249.— Exophthalmic goitre. 

in the course of the disease both lobes become enlarged. Pulsa- 
tion of the cervical vessels may be seen or felt in the mass. The 
size of the goitre varies from time to time. It comes to a standstill 
often for months at a time, and increases in size fitfully and irreg- 
ularly. The nature of the disease is best recognized by t\\Q protru- 
sion of the eyeballs, or exophthalmos. At first there is but slight 
increase or pressure against the lids. The aperture of the palpebrse 
is increased, the eyes appear more full and large. The movements 
of the upper eyelid and globe fail to correspond. The globe fol- 
lows the lid so slowly in looking upward as to show a line of con- 
junctiva, and in looking down the pupil is slow to appear (Grafe). 
As the protrusion becomes greater it amounts to a positive deformity 



588 



EXOPHTHALMIC GOITRE. 



and attracts attention at a glance. The lids may so far fail to cover 
the globe as to develop a condition of dryness and xerophthalmos, in 
which the eye, if unprotected by mechanical means, may actually 
slough away. 

Etiology.— It has been found very difficult to account for this 
singular association of symptoms — palpitation of the heart, enlarge- 
ment of the thyroid, and exophthalmos. The lesion would seem to 
lie with the nervous system, which is the only means of intercom- 
munication. But the revelations of autopsies have not disclosed as 
yet definite lesions. It is usually considered an affection of the sym- 
pathetic nervous system. Injury or irritation of any part of the 




Fig. 250. 

Fig. 250.— Exophthalmic goitre. 
Fig. 251.— Exophthalmic goitre. 



Fig. 251. 

Enlarged thyroid and prominent eyes. 

Defective descent of upper lid in looking down (Wilks). 



sympathetic may produce the condition. The symptoms may be 
worked out by lesions of the medulla, and the tendency in our day is 
to consider the disease as an affection of the medulla through the 
vaso-motor nerves. The toxic or chemical theory attributes the dis- 
ease to the affection of the thyroid gland, disease of which is said to 
produce exophthalmic goitre, while destruction of it produces myx- 
cedema. Support for this view is found in the improvement which 
sometimes occurs after operation, thyroidectomy, and after adminis- 
tration of thyroid extract. 

The diagnosis rests upon the tripod of symptoms, the association 



MYXCEDEMA. 589 

of palpitation, goitre, and exophthalmos, preceded often by tremor 
and attended by great nervousness, i. e. , neurasthenia, 

The prognosis, so far as life is concerned, is not unfavorable. 
The disease is obstinate. Absolute recoveries are exceptional. 
Periods of quiescence occur, and the most that may be promised, as 
a rule, is arrest at the present stage. Cures have occurred under 
hygienic means, change of climate, sea air, mountain resort, etc. 
All cases are benefited in this way. Death from heart failure is 
sometimes sudden. 

Treatment. — The agent most potent in relief of the condition is 
electricity. One pole, the anode, is put at the nape of the neck, the x 
other, the cathode, is applied in front of the sterno-cleido muscle, and 
the constant current is allowed to run from five to ten minutes. The 
tumultuous action of the heart is often stilled in this way. The ice 
bag may be applied at night over the heart, with intervening towels. 
Arsenic is the remedy in most general use. Its virtue is empirical. 
Atropine, ergot, and iodine are agents which may seem to be 
adapted to an individual case, and may be tried in succession with the 
hope, usually vain, of securing relief. Tremor may be stilled with 
hyoscy amine gr. T1 ^. The irregularities of the heart may be checked, 
if tumultuous, with the bromides, gr. xxx.-xl. largely diluted. 
Sleep may be secured with small doses (gr. v.-x.) of chloral with 
a glass of wine, or sulphonal gr. x.-xv. in hot milk, two hours be- 
fore bedtime. Sometimes the heart requires stimulus. Digitalis is 
the first resort. It is given in small dose, five to ten drops, three 
times a day. To relieve the arterial tension digitalis is substituted, 
often with great benefit, by the tincture of strophanthus gtt. v.-x. 
three times a day. The natro-benzoate of caffeine, two or three 
grains every two or three hours, may give comfort for the day. 

The author has seen sometimes immediate benefit, but as yet no 
cure, from the use of the fresh thyroid extract subcutaneously and 
from the administration of the desiccated extract in powder, gr. 
v.-xv. in capsule, three or four times a day. Wette reported of 
thirty cases of thyroidectomy collected in the literature twenty-six 
improvements or cures, two deaths. Trendelenberg declares that the 
cures are not permanent. 

Excitement and imprudence are quickly punished. The habits of 
life must be nicely regulated. 

MYXCEDEMA. 

Disease or destruction (extirpation) of the thyroid gland begets 
or is followed by three sets of symptoms — nervous, vascular, and 
metabolic. The mind becomes melancholy, morose, apathetic, and 
imbecile. Palpitations set in, tachycardia, as in Basedow's disease, 



590 ARTERIOSCLEROSIS. 

with pallor and anaemia. The number of blood corpuscles is sensibly 
reduced, and the haemoglobin is correspondingly lessened. The most 
curious change occurs in the tissues, which show a mucoid degenera- 
tion with oedema. This so-called myxoedema is most visible in the 
face and hands, which swell to assume a gross and revolting look. 
The cheeks are purled out, the lips protrude like sausages, the chin 
bulges, and the neck grows so big as to make it difficult to turn the 
head. The hairs fall, the eyebrows are scant, the crines axillares 
absent altogether. The eyelids swell to such extent as to produce 
ptosis. The cornea is often barely visible through a narrow slit. 
The face is a repulsive mask. At the same time the strength is 
greatly reduced, the patient pants on walking or must actually ob- 
serve the recumbent posture. 

Schiff observed that the dangers of thyroidectomy could be ob- 
viated by the insertion into the abdominal cavity of the thyroid gland 
of another animal of the same species. Horsley suggested the prin- 
ciple in man, and Bircher (1890) actually put it in practice with good 
results. Lannelongue, Walter, Macpherson, Geraud followed quick- 
ly with cases. Howitz, Mackenzie, and Fox fed the gland of the sheep 
to patients thus affected. Murray and Beatty injected the extract 
of the gland subcutaneously, and White administered it internally. 
The dose of the desiccated gland extract is five to fifteen grains three 
times a day. All patients are improved, many are actually cured, 
under this treatment. 

Acute goitre, which is now believed to be an infectious disease 
whose cause is introduced with the drinking-water, is sometimes 
quickly and completely cured by large doses of quinine. 

DISEASES OF THE BLOOD VESSELS. 
ARTERIO-SCLEROSIS. 

Arterio-sclerosis ; atheroma (<af3-7/p?/, porridge — i.e., grumous). — 
Degeneration of the arteries, fatty and atheromatous, usually at- 
tended with thickening of the intima, later also the media. Arte- 
rio-sclerosis is a natural process in age, where it is found associated 
with other evidence of senescence, arcus senilis, atrophy of the kid- 
neys, and general atrophy, and the degeneration is an expression of 
involution. 

The condition is precipitated in maturity and youth especially by 
alcohol, syphilis, and gout ; hence it is that " a man is as old as his 
arteries." It may occur in any condition which raises the pressure 
in the arterial system — hard work, luxury, sedentary life — and is 
found usually in association with hypertrophy of the left ventricle. 
It arises also in connection with retention of toxic elements, diabetes,. 



ARTERIOSCLEROSIS. 591 

uraemia, gout. Men are affected more frequently than women, old 
people than young. The vessels under greatest strain suffer first — 
to wit, in the order of descending frequency, the ascending aorta, 
the arch of the aorta, the descending aorta, the splenic, iliac, and 
crural arteries, coronary arteries, cerebral arteries, uterine arteries, 
brachial, ulnar, radial artery, etc. The disease process shows itself 
as a simple thickening of the intima from hyperplasia of the connec- 
tive tissue, and is followed by fatty degeneration with the deposit of 
calcareous matter, often by subsequent ulceration and cicatrization. 
The vessel loses its resilience, becomes thick and rough. Deposits 
of chalky matter, which aggregate to form plates, substitute the 
natural tissue. With the disintegration of this matter, detritus, fatty 
matter, cholesterin, fibrin from the blood are deposited upon the sur- 
face to constitute the atheromatous — i.e., gruel-like — ulcer. In con- 
sequence of the increased resistance offered to the action of the heart 
the vessel becomes elongated, serpentine, dilated into aneurisms, and 
so friable as to suffer rupture. The thickening of the intima is often 
so great as to lead to thrombosis with more or less 23erfect occlusion 
(endarteritis obliterans). 

Symptoms. — The condition is sometimes easily recognized. Athe- 
romatous vessels may be seen or felt in the radial and temporal re- 
gions as tortuous, pulsating tubes, unyielding, rigid to the touch. 
Sometimes the artery at the wrist feels like a chain of beads. More 
frequently these vessels escape while internal arteries are affected. 
Hypertrophy of the heart without other explanation (valve lesion, 
B right's disease), in association with disease which might produce 
the condition, may lead to diagnosis. Attacks of angina pectoris 
and cardiac asthma may indicate sclerosis of the coronary arteries. 
The diameters of the heart are increased on account of hypertrophy 
or dilatation. The impact is more violent and extensive, the apex 
somewhat dislocated. The pulse is full, strong, and unyielding : it 
may be retarded. The aortic valve sound, heard best at the base at 
the second right interspace, is accentuated. Haemorrhage or evi- 
dence of softening may indicate rupture, aneurismal dilatation, 
thrombosis or embolism of the brain arteries. Sooner or later super- 
vene the signs of dilatation and degeneration of the heart, with 
oedema, stasis, sometimes with uraemia in connection with B right's 
disease and with gangrene in connection with diabetes. 

The diagnosis rests upon the hypertrophy of the left ventricle in 
association with increased tension in the vessels, independent of phy- 
siological overgrowth, valvular disease, Bright's disease, etc. 

The prognosis is always grave. The patient stands in constant 
danger of cerebral haemorrhage, thrombosis, and embolism. Through 
affection of the coronary arteries he is menaced also with angina 



592 ANEURISM OF THE AORTA. 

pectoris and cardiac asthma. With the perfection of proper appara- 
tus it must soon be the case that estimate of the duration of life, as 
for annuities, life insurance, etc., will be based largely upon the pres- 
sure of the blood in the arteries. 

The treatmeni must address itself to the cause, and may be effi 
cacious only when the canse — alcoholism, gout, diabetes — may be re- 
moved. The diet and the mode of life must be regulated to the new 
or developing conditions. Exercise in the open air (horseback), the 
free libation of mineral waters, simple, wholesome food, regular 
sleep, good habits, and cheerful surroundings longest postpone or 
best protect the patient against the remoter evils of this disease. 

Alanus advises the exhibition of a mixed diet, especially of meat, 
basing the recommendation upon the observation that the Hindoos, 
who feed exclusively upon rice, and certain quite young monks in 
cloisters, with other vegetarians, suffer premature arterio- sclerosis 
(atheroma) from deposit of the excess of mineral salts. 

ANEURISM OF THE AORTA. 

The lack of resilience imparted t o an artery by arterio-sclerosis 
causes it to yield before the impact of blood and leads to dilatation 
of its walls. The dilatation may be saccular, cylindrical, or spindle- 
shaped. Because subjected to greatest pressure it occurs most fre- 
quently in the ascending aorta and in the arch of the aorta. Such 
a dilatation constitutes an aneurism (avevpuvoo, to widen), which 
may vary from a scarcely perceptible enlargement to the size of a 
man's head. The sac of the aneurism is filled with blood, which 
coagulates in layers, and from which fragments may be detached to 
constitute emboli. Men are affected more frequently than women, 
because men are the more frequent subjects of the cause of arterio- 
sclerosis — to wit, syphilis, alcohol, hard work, and gout. The great 
majority of cases occur, therefore, between the ages of thirty and fifty. 

The symptoms depend chiefly upon pressure, and occur in num- 
ber and severity according to the direction of the growth and the 
structures implicated. Aneurism remains for a long time latent. 
Symptoms are absent altogether in one-fifth of cases. Among the 
subjective symptoms may be mentioned sensations of fulness, pul- 
sation and oppression, pains in the chest or back, vertigo, head- 
ache, hoarseness, etc. As these symptoms may be all due to many 
causes, the objective symptoms assume prominence. Inspection may 
reveal distention, bulging of the chest, or the actual presence of a 
pulsating tumor. Usually the pulsation is felt on the right or left 
of the sternum, or between the spinal column and the scapula, ac- 
cording as the aneurism is situated in the ascending aorta, arch of 
the aorta, or descending aorta. Sometimes it is first appreciated by 



ANEURISM OF THE AORTA. 



593. 



the finger introduced behind the sternum in the neck, when the head 
is retracted and the larynx lifted up. The aneurismal bruit may 
be heard in these situations or along the line of the carotids. As 
the disease advances, a tumor, most frequently at the second right 
interspace, becomes more and more visible, or dulness in this region 
indicates its presence. Soft, blowing sounds are heard on ausculta- 
tion in both systole and diastole. The sounds are intensified with 
insufficiency or stenosis at the aortic valves. The heart is often dis- 
placed toward the left in aneurism of the ascending aorta, and to- 
ward the right in aneurism of the descending aorta. Sometimes the 
blood wave is unequally distributed to the two sides, so that the 
left radial and carotid pulse may be feebler or retarded. The 
sphygmograph shows reduction in the line of ascent, absence of sec- 





Fig. 252. 
Fig. 252.— Aneurism of femoral artery : a, adventitia 
entrance of sac (Weber). 

Fig. 253.— Aneurisms, a, a, of the hypogastric artery. 



Fig. 253. 
intima ; c, muscularis, present only at 



ondary vibrations. The veins of the thorax and the upper extremi- 
ties, on account of interference with the return current from com- 
pression of the right auricle, may become tortuous, and oedema may 
develop upon the side of the chest— conditions more frequently 
encountered in mediastinal tumors than aneurisms. Dyspnoea and 
cyanosis may develop from direct compression of the trachea and 
bronchi, and dysphagia from compression of the oesophagus. 
Hoarse?iess of voice, aphonia from paresis and paralysis of the left 
vocal cord, is often an early symptom of pressure on the left recur- 
rent nerve. Double paralysis occurs more frequently in tumors. 
Pressure upon the brachial plexus develops pain, paresthesias, and 
paresis in the upper extremities. The gradual development of the 



594 



ANEURISM OF THE AORTA. 



aneurism leads to consumption, usury, of everything before it, in- 
cluding bones, sternum, vertebral column, etc. 

Aneurism of the Abdominal Aorta reveals itself as a pulsating 
tumor in front of the vertebrae, at first above the umbilicus. Aneu- 
rism at this seat remains for a long time latent, and is usually sus- 
pected on account of obstinate pains (gastralgia, enteralgia) and 




Fig. 254.— Aneurism of the aorta : a, aorta ; c, a fusiform aneurism of ascending aorta commu- 
nicating at b with the dilated aorta ; d, rib adherent to sac of aneurism ; e, shrunken aortic valves. 



paresis in the abdomen or lower extremities. The condition is often 
mistaken for neuralgia or rheumatism for months, sometimes for 
years, until the tumor makes itself manifest. Sometimes the diagno- 
sis is only made by the collapse which follows rupture. The aneu- 
rism may thus discharge itself suddenly with sudden death, or 
gradually with the symptoms of chronic anaemia. 

Aneurism of the aorta may at any time terminate suddenly, or 



PHLEBITIS. 



595 



may last for years with slight or severe symptoms. Aneurism of the 
thoracic aorta may discharge itself into the oesophagus or stomach 
to be attended with haematemesis, or into the trachea or bronchi to 
produce suffocation, into the pericardium to cause sudden death. On 
account of defective nutrition it is often attended with tuberculosis. 
Aneurism of the abdominal aorta may discharge itself into the peri- 
toneal sac, left pleura, intestine, and stomach. Sometimes the blood 
in coagula fills the aneurism and the patient makes a perfect recov- 
ery. 

The diagnosis rests upon the recognition of a cause — alcoholism, 
syphilis, gout, trauma with the signs of pressure, 
aphonia, oedema, dysphagia — and the discovery 
of a fluctuating, pulsating tumor with bruits at 
the second right interspace and in the jugulum. 
Abscess is distinguished by its greater extent, 
tenser walls, points or surfaces indicating suppu- 
ration. Malignant growths show no fluctuation 
or pulsation. Doubt which may not be settled 
by careful examination may be dispelled by the 
introduction of the finest needle of the aspirator — 
a procedure, according to Fiirbringer, unattended 
with any danger. 

The prognosis is always grave. The danger 
is from rupture and compression of important 
structures. 

The treatment should address itself to the 
cause in the cure of alcoholism, syphilis, and gout. 
The best outlook is offered in syphilitic arterio- 
sclerosis, where S3 T stematic use of mercurial oint- 
ment and iodide of potassium may be followed 
with the best results. Eepeated subcutaneous injection of ergotin 
or sclerotinic acid sometimes leads to contraction of the sac. Acu- 
puncture and galvano-puncture, the introduction of fluids, the intro- 
duction of solids (wire) to bring about coagulation of the blood, are 
procedures, not unattended with danger (embolism), sometimes re- 
sorted to in protection against the greater evils of aneurism. 




Fig. 255. — Section of 
aneurism filled with clot 
surrounded by dense lay- 
ers of connective Cfibrous) 
tissue (Wagstaffe). 



PHLEBITIS. 

The veins show the same changes as the arteries, but less fre- 
quently and in a less pronounced form. Fatty degeneration, athe- 
roma, sclerosis, are changes which begin in the intima of the veins as 
well as in the arteries, and lead likewise to dilatation, phlebectasis, 
varices, rupture. The most common lesion is the formation, in con- 



596 



PHLEBITIS. 



nection with the infections (typhoid fever, pneumonia, septicaemia, 
dysentery), of a thrombus, which occurs especially in the veins of the 
lower extremities (milk leg) and the pelvis, not infrequently in the 
sinuses of the dura mater, more rarely in the portal veins — pylephle- 
bitis. Cicatrization may occur in the region of the thrombus, with 




Fig. 256.— Obliteration of right femoral vein, showing remains of a thrombosis three years before 
death : a, site of obliteration ; 6, c, d, connective tissue in interior t of vein and its branches ; e r 
recent thrombus. Natural size (Ziegler). 

contraction and obliteration, so that the vein may be converted 
into a fibrous cord. Circulation must now be conducted by col- 
lateral veins. Calcification may occur, with the formation of phle- 
boliths, or toxic processes may result in suppuration. 



CHAPTEE VIII. 

DISEASES OF THE BLOOD. 

Affections or anomalies of the blood concern both quantity and 
quality, and in either case are felt from the nature and distribution 
of this circulating fluid in every organ of the body. 

To get reliable data blood must be examined fresh. Fortunately, 
a drop or two, as taken with a fine lance (not with a needle) from 
the finger or from the lobe of the ear, suffice for all clinical pur- 
poses. Blood thus collected, as it exudes, is studied without pres- 
sure from the cover glass, that first the process of nummulation may 
be observed. This process occurs in all healthy blood. Absence of 
it or imperfect performance of it indicates at once the existence of a 
grave disease. Second, the fresh drop is studied as to its corpus- 
cular elements — their number, size, color, shape, nucleation, relative 
proportions, etc. A solution of common salt, 0. 75 per cent, will keep 
the corpuscles unaltered for longer study. 

Excesses in quantity are distinguished as plethora (nXr/SoS, 
fulness), which is recognized by fulness of vessels, flushing of the 
face, headache, tension of the pulse, increased impact of the heart, 
palpitation, etc. Such plethora is noticed after suppression of hab- 
itual haemorrhages, haemorrhoids, epistaxis, menorrhagia, and after 
transfusion. Flushing of the face, with dilatation of vessels, may 
mean not general but local plethora in paretic and dilated blood 
vessels. The plethora of the drinker, in association with acne, may 
be thus wholly paretic and local. Plethora is called serous when the 
proportion of water is above eighty per cent. Serous plethora, which 
gives rise to local oedema and general anasarca, is observed more 
especially in disease of the kidneys. The blood is diminished in 
amount after heavy losses, haemoptysis, haematemesis, or other haem- 
orrhage, to constitute the condition called oligaemia or, more com- 
monly but improperly, anaemia. 

Anomalies of composition exist in hydraemia (vSaop, water), a 
relative increase of water, observed especially in Bright's disease ; 
and anhydraemia, a relative decrease of water, observed after pro- 
fuse watery discharges, diarrhoea, dysentery, cholera morbus, and 
Asiatic cholera. 



598 DISEASES OF THE BLOOD. 

Slight inspissations of the blood occur in the course of fevers, 
after the thirst cure, etc. Changes in the haemoglobin are best 
estimated by means of Gowers' haemoglobinometer. The normal 
per cent of haemoglobin is, in the male, 13.77; in the female, 12.59. 
Information sufficiently accurate for practical purposes is obtained by 
the colorimetric test. The color imparted by dissolving a drop of 
blood in distilled water is compared with a previously prepared nor- 
mally colored glass. The glass devised by Fleischl gives a scale of 
percentage. It is highest in the new-born, is reduced to one-half in 
the first years of life, increases from the age of twenty-one to forty- 
five, and is later again reduced. The haemoglobin corresponds 
closely, but not absolutely, to the number of red blood corpuscles. 
It may be increased 120 per cent above the normal. It is reduced 
in anaemia in all its forms, in malnutrition from any cause, tuber- 
culosis, cancer, or other cachexias. It is especially diminished in 
amount in chlorosis, pernicious anaemia, and leukaemia. The reduc- 
tion in leukaemia runs parallel with the reduction in red blood cor- 
puscles, while in chlorosis, notwithstanding the reduction of haemo- 
globin, the corpuscles may be normal in number. Haemoglobin 
may be reduced 10 per cent below the normal. In marked reduction 
the blood is visibly pale. 

The albuminates exist in the blood in combination with the 
haemoglobin and in solution in the plasma (8 to 10 per cent). In- 
crease (hyperalbuminosis) occurs in association with inspissation of 
the blood; decrease (hypalbuminosis) with hydraemia and marasmus. 

Fibrin, which exists normally in the proportion of 0.1 to 0.4 per 
cent, may be increased (hyperinosis) to 1 per cent, as in croupous 
pneumonia, acute rheumatism, etc. ; or decreased (hypinosis) in the 
acute infections and various poisonings (prussic acid, sulphuretted 
hydrogen, alcohol, etc.). 

Salt should exist in the blood in the proportion of 0.85 per cent. 
Reduction is especially noticed in the sputum of pneumonia, and 
reappearance is recognized evidence of resolution. The sign has 
lost much of its value since it has been learned that the variations 
are largely due to food. Reductions are in all cases speedily regu- 
lated. 

Increase of fat, which exists normally in the proportion of 0. 1 to 
0.2 per cent, shows itself in increased, or milky, opacity of the 
plasma. It is observed after excessive indulgence in fat, obesity, 
any disease attended by albuminoid degenerations, affections of the 
liver, alcoholism, and marasmus. Globules of fat may escape from 
the bone marrow after injuries to bone, to block capillaries in the 
lungs and to produce the dangerous affection known as fatty em- 
bolism. 



DISEASES OF THE BLOOD. 599 

Increase of grape sugar, which exists normally in the proportion 
of 0. 1 to 0. 15 per cent of the plasma, is observed after haemorrhage 
and in the course of diabetes. Any excess above 0. 9 per cent is ex- 
creted with the urine. 

Urea, which may exist in normal blood in the proportion of 0.016 
per cent, and urates (traces), accumulate in consequence of disease 
of the kidneys and failure of elimination, to produce the condition 
known as uraemia (ovpov, urine). Increase of uric acid occurs in 
gout. 

Increase of bile pigment, cholaemia (xoXrj, bile), shows itself in 
icterus. Small quantities are detected in the blood by filtration of 
the serum, withdrawn by cupping and separated from the clot, and 
coagulation at 70° to 80° C. After repeated heating to 50° to 60° C, 
serum assumes, in the presence of bile, a grass-green color. Disso- 
lution of the red blood corpuscles, with liberation of coloring matter, 
constitutes haemoglobinaemia and haemoglobinuria. These condi- 
tions occur in consequence of the infections, freezing, extensive 
burns, after transfusion of heterogeneous blood, in poisoning by chlo- 
rate of potash, tincture of iodine, arsenic, etc. (Stintzing). Melanae- 
mia results from dissolution of the red blood corpuscles and libera- 
tion of black pigment granules in the course of malaria. Small 
quantities of air may make the round of the circulation and be ab- 
sorbed without damage. Larger quantities make the blood foamy, 
block the right heart or pulmonary vessels, and thus produce sudden 
death. 

Alterations of the corpuscular elements concern number, color, 
form, and composition. 

Healthy male blood should contain 5,000,000 red corpuscles, fe- 
male -1,000,000, to the cubic millimetre. Plethora of corpuscles 
(polycythemia) {7to\vs, kvtos, many cell) may increase the number 
to 7,000,000, with increase of haemoglobin from 13 to 16 per cent. 
Conditions which lead to inspissat'ion of the blood, watery dis- 
charges, etc. , produce this effect. Blood corpuscles may be increased 
in high degrees of heart failure to 8,800,000 in one cubic millimetre. 

Decrease (oligocythaemia) is a constant attendant of anaemia, 
chronic diseases marked by malnutrition, and marasmus. The blood 
corpuscles may be decreased in pernicious anaemia to 1,000,000 or 
500,000 to the cubic millimetre. 

Blood corpuscles increased in size to a diameter of 9.5-10.0 jli 
and over are called giant blood cells — macrocytes. They are seen in 
certain anaemias, chlorosis, cholaemia, lead poisoning, especially after 
haemorrhages, and often in connection with microcytes. Corpuscles 
decreased to 6.5 pi are called dwarf corpuscles. Microcytes are 
small, globular bodies which are found in high fever, severe chronic 



600 BLOOD PARASITES. 

anaemia, extensive burns, poisoning by morphia, carbolic acid, and 
especially in septicaemia. Megaloblasts are giant cells with nuclei. 

Changes of form are distinguished as poikilocytosis (7Tozjz'Ao£, 
varied). Such alterations are seen in light degree in chlorosis, leu- 
kaemia, and secondary anaemia ; in high degree in progressive per- 
nicious anaemia. 

The number of white blood corpuscles is more variable than that 
of the red. A cubic millimetre of blood contains, on the average, 
5,000 to 10,000 white corpuscles. The proportion of white to red 
ranges between 1 : 400 and 1 : 1000. Amoeboid motion continues, 
under heat and moisture, two to three hours. The leucocytes, as 
they may be stained, are divided (Ehrlich) into (1) basophile, which 
may be colored with basic aniline dyes (methylene violet, fuchsin), 
found in connective tissue ("mast" cells) but not in normal blood ; 
(2) eosinophile, whose granules take up the acid dyes, especially 

eosin, rarely found in normal blood ; 

•g- TV ><, )^ (3) neutrophile, colored with neutral 

Z> * J J dyes (methylene blue, acid fuchsin), 

gf^> / w xf" J % which form the bulk of the white cor- 

0t ^ # > c { 7 puscles of the blood. All the pus cor- 

puscles belong to this group. 

Fig. 257.— Poikilocythaemia : a, nor- -vxri„ *j. Li j l i? j_i 

mal, 6, reduced red blood corpuscles; . Wmte blood Corpuscles are further 

c different forms of degenerated red divided into mononuclear and polynu- 

(Ztegirr 80168 ^ ^ 1007 ' 6 ^' X m ' clear cells " The mononuclear cells con- 
stitute 25 per cent (varying between 15 
and 35 per cent) and the polynuclear 75 per cent of the whole number. 
Transition forms are not infrequent. 

Absolute increase in number indicates either leukocytosis or leu- 
kaemia. Leukocytosis is a relative increase from 1 : 400 to 1 : 50. It 
occurs, as a rule, in the course of the acute infections and chronic 
wasting diseases. The proportion may be reduced in the death ago- 
ny to 1 :5 (Litten). The reduction reaches in leukaemia its highest 
grade ; it may fall to 1 : 1. Increase in the eosinophile cells indicates 
leukaemia. The sign is of not so much value in children, where 
these cells may be increased to 15 to 20 per cent of the whole num- 
ber of leukocytes, independent of affections of the spleen or bones. 



BLOOD PARASITES. 

The parasites found in the blood are both animal and vegetable. 
The animal parasites, Distoma, Filaria, and Plasmodium malariae, 
have been already described. 

In examining for vegetable parasites (bacteria), the end of the 
finger punctured for blood must be first thoroughly washed with soap 



BLOOD PARASITES. 601 

and sublimate solution 1 : 1000, and this solution subsequently 
washed off with, first, alcohol, then ether. The lancet, cooled after 
having been heated to redness, makes the slight cut necessary to se- 
cure the blood. The slide and cover glass must be cleaned and dis- 
infected like the finger. The drop of blood should be dried under a 
bell-glass cover and then heated, or should be three times drawn 
through the flame of an alcohol lamp to fix it. The preparation is 
stained with the aniline or other coloring matters, as already specified. 
A good microscope is required, provided with a condenser, best with 
the Abbe illuminating apparatus. 

Of the bacteria found in the blood, the Bacillus anthracis and the 
recurrens spirillum are sufficiently distinguished, so far as the diseases 
of man are concerned, by their morphology alone. The bacillus of 
glanders is readily recognized by inoculation, and the typhoid bacil- 
lus demands culture to confirm a diagnosis. 

The tubercle bacillus may be disclosed after the manner speci- 
fied in the study of the sputum, but is more readily shown by the 
method of Gabett. The preparation of blood is immersed two min- 
utes in the solution of carbol f uchsin specified, in a watch glass. It 
is then washed off with distilled water, and thereupon immersed for 
about one minute in a methylene- blue and sulphuric-acid solution 
(methylene blue one to two parts ; sulphuric acid, twenty-five per 
cent solution, one hundred parts ; both solutions to be filtered). The 
methylene-blue solution is to be decolorized immediately and stained 
as specified in the study of the sputum. A power of four hundred 
diameters displays the deep-red tubercle bacilli on a delicate blue 
ground without other tone of red. These solutions of Gabett have the 
advantage that they keep for months. The examination of the blood 
is made only in acute miliary tuberculosis, in which all sputum is 
absent ; and as the bacilli are in all cases so few and far apart, the 
blood, a venesection-cupful, should be allowed to stand several 
hours and the sediment and clot broken up fine with a glass rod. 
After this procedure an unmistakable specimen or two is usually 
found. But while a positive discovery declares the diagnosis, nega- 
tive evidence does not exclude the disease. 

Lepra bacilli have been found in the blood in the beginning of 
a new eruption. The diagnosis is usually made, however, from the 
masses in the skin. The bacilli of lepra closely resemble those of 
tuberculosis, but differ from them and all other bacteria in the fact 
that they are colored red by immersion six minutes in a concentrated 
alcoholic solution of f uchsin and subsequent washing of the super- 
fluous color in a mixture of nitric acid one part, alcohol ten parts. 
All other bacteria are colorless — i. e. , are decolorized by this method. 






602 ANAEMIA. 



ANtEMIA. 



Ancemia (av, without, aipia, blood), more properly oligaemia 
(oXiyoS, little), acute and chronic, is called primary or essential 
when its cause is concealed, and secondary when it occurs in the 
course, or in consequence, of various discoverable diseases. 

Anaemia is most acute after direct loss of blood, from whatever 
cause, whether the haemorrhage be manifest or concealed — ulcer of 
the stomach, rupture of aneurism, tubal pregnancy, etc. Tolerance 
to haemorrhage varies. Infants and aged people fall into collapse 
with losses which might be safely endured at maturity. "Women en- 
dure haemorrhage better than men, the thin better than the obese. 
The loss of a third of the whole amount of blood is necessarily fatal; 
the loss of a less amount, whereby the blood corpuscles are reduced 
one-half— from 5,000,000 to 2,500,000 to 2,000,000 in one cubic milli- 
metre, in disproportion thus to the amount of the blood itself — is 
often fatal. Blood corpuscles are rapidly restored in convalescence 
at the rate of 150,000 to 170,000 per day (Laache). The haemo- 
globin is not so quickly restored; hence the more persistent pallor of 
the skin. 

Symptoms. — Acute anaemia, as from haemorrhage, is attended by 
pallor, cyanosis, and collapse; the skin is cold and clammy; the 
heart's action is weak and fluttering. Ringing in the ears, vertigo, 
dyspnoea, precordial anxiety, retching and vomiting, faintness, con- 
vulsions, and loss of consciousness are the common signs of rapid 
loss of blood. 

Chronic anosmia results from repeated haemorrhage or other 
losses, prolonged lactation, onanism, suppuration, or other profuse 
discharge, diarrhoea, albuminuria, leucorrhoea, fever, melancholia, 
protracted insomnia, chronic infections, tuberculosis, malaria, scurvy, 
syphilis, cancer, certain intestinal parasites, especially those which 
draw blood, anchylostomum, etc. 

Chronic anaemia shows itself in reduction of the red corpuscles. 
It is most frequently seen in connection with cachexia, cancer, 
amyloid degeneration, tuberculosis, malaria, syphilis, poisoning by 
arsenic, lead, mercury. In aggravated cases there is also poikilo- 
cytosis. In these cases the albuminates may fall from 8 to 4 per 
cent and the specific gravity from 1030 to 1013. Cachexia develops 
gradually; the face is gray, or greenish gray, from deposit of pigment 
matter from disintegrated blood cells. On account of the lack of nutri- 
tion emaciation gradually develops, the fat disappears, later the mus- 
cular tissue; the patient falls into marasmus; the action of the heart 
is enfeebled; the valves show relative insufficiency, and, in conse- 
quence of irregular vibration, yield to auscultation a systolic mur- 
mur. Anaemic murmurs are heard also in the course of the arteries 



ANAEMIA, 603 

and veins, especially at the root of the neck. The heart is excitable 
| through weakness and without apparent provocation. The symp- 
toms of stasis supervene sooner or later — oedema about the ankles, in 
! the serous sacs, cyanosis, diminution of urine, albuminuria, bron- 
chial catarrh, and oedema of the lungs. In consequence of nutritive 
change in the endothelium, marantic thrombosis is wont to occur in 
various veins, including the sinuses of the brain. Epistaxis, retinal 
haemorrhage, metrorrhagia, are haemorrhages which may occur by 
diapedesis in cases of aggravated anaemia. Insomnia, disturbances 
of special sense, paraesthesia, hyperaesthesia, mental affections, hal- 
lucinations, vary the scene. All anaemic patients are more or less 
dyspeptic, partly from diminution of secretion, partly from atony. 
Menstruation is disturbed in every way. 

The diagnosis of anaemia is usually easy, and the prognosis de- 
pends upon the cause. Loss of blood up to one per cent of the 
weight of the body is made up in two to five days ; up to three per 
cent, in five to fourteen days ; in larger amounts, in fourteen to thirty 
days (Lyon) . The haemoglobin, as stated, is restored less rapidly than 
the corpuscles. 

In the treatment of anaemia it must be remembered that the con- 
dition is usually only secondary. Address must be made to the 
cause. The treatment of anaemia may resolve itself into the treat- 
ment of tuberculosis, Bright's disease, diabetes, affections of the 
uterus, gastric catarrh, intestinal parasites, etc. Acute cases, as 
after haemorrhage (gastric ulcer), are sometimes rescued by the 
transfusion of the physiological salt solution of one to one and a half 
pints, one-half drachm to the pint. Transfusion may be made into 
the veins of the arm or upper thigh, or, more safely, under the 
skin as in the treatment of cholera. In cases of extreme collapse 
the intravenous method is to be preferred. Patients apparently in 
articulo mortis have been rescued in this way. Alcohol may be in- 
troduced also subcutaneously, or, better, camphor dissolved in sul- 
phuric ether, in the proportion of 1 : 10, introduced in syringeful 
doses under the skin. In subacute or chronic cases the best remedy 
is iron. What form of iron is given matters but little. Many prac- 
titioners still prefer the old Blaud pill. The following is the original 
formula of Blaud (1831) : 

^ Ferri sulphatis gr. xv. 

Potassii subcarbonatis , gr. xv. 

Reduce separately to a very fine powder. Mix very slowly, little by little, 
and add — 

Mucilaginis adragantis q. s. 

Rub thoroughly and forcibly to a mass, and divide into forty-eight pills. 

The more modern preparations, albuminated or peptonized, owe 



604 PERNICIOUS ANAEMIA. 

their superiority only to the power of suggestion. Probably the 
same explanation will account for the virtues of the artificial haemo- 
globin, as we do not understand as yet the iron combination in the 
complex molecule haemoglobin. The tincture of the chloride of iron in 
sweetened water is indicated with any tendency to diarrhoea. Gene- 
rally the tendency is toward constipation. The saccharated car- 
bonate may be given in teaspoonf ul doses three times a day. The 
compound mixture of iron is an unpleasant but very efficacious 
form ; dose, one tablespoonful three times a day. A pill of reduced 
iron, one to two grains at a dose, in connection with one or two 
drops of Fowler's solution of arsenic, makes a fine blood tonic, 
ftoncegno water contains more arsenic than iron. Food and fresh 
air are even more essential agents in the successful treatment of 
anaemia. 

PERNICIOUS ANEMIA. 

Progressive, essential, idiopathic anaemia. 

Etiology. — The disease occurs more frequently in maturity, ex- 
ceptionally in children. Women are attacked more frequently than 
men, on account of the liabilities of pregnancy. The disease is more 
common in Europe, especially in Switzerland, and is rare with us. 
Like all diseases whose cause is obscure, it has been attributed to 
accidents or conditions which preceded it (thus, to defective nutri- 
tion, exhausting discharges, frequent pregnancies, haemorrhages, 
ulcers of the stomach and intestine, malaria, syphilis, cancer, alco- 
holism, intestinal parasites, anchylostomum, bothriocephalus), some- 
times without other foundation than sequence. Von Jacksch claims 
a parasitic origin ; Petrone and Holtz consider the disease infectious. 

Symptoms. — The most obtrusive symptom is the pallor of the 
skin and exposed mucous membranes. The face is white and the 
mucous membranes blanched. On account of the extreme poverty of 
the blood, oedema occurs about the ankles and face, with effusions 
later into the serous sacs. Nevertheless nutrition is preserved and 
the adipose tissue is not lost. The temperature is subject to great 
fluctuation. The disease is usually attended with fever, hence the 
synonym ' ' febrile anaemia. " It is usually of more or less remittent 
type. The temperature rises and falls without discoverable cause, 
and the subjective condition is often better during fever (Van Noor- 
den). Disturbances on the part of the digestive system are fre- 
quent. Thirst, foetor of the breath, nausea and vomiting, obstinate 
diarrhoea, belong to the condition. On the other hand, the appetite 
is sometimes voracious and constipation prevails. The epigastrium 
is always tender to pressure. The urine is sometimes increased, 
sometimes diminished ; it may show increase of indican, uric acid, 
and peptones. The brain suffers for want of healthy blood. Some 



PERNICIOUS ANEMIA. 



605 



patients are excitable, others indifferent. Insomnia may alternate 
with sopor. Neuralgias, parcesthesioe, par eses, apoplectiform at- 
tacks, and delirium, even outbreaks of mania, may occur in the 
course of the disease. Patients complain of tceakness, which is 
manifest from the beginning. 

The blood is thin and pale, more the color of amber than 
blood (Weiss), exceptionally dark (Gusserow), poor in iron (Roki- 
tansky). The blood corpuscles suffer enormous diminution, be- 
low a million down to half a million — in a case recorded by Quincke 
143,000 in one cubic millimetre. The hcemoglobin is reduced to 
one-tenth of the normal, less in degree than the red blood corpuscles 
— a disproportion considered characteristic of pernicious anaemia. 



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Fig. 238.— Pernicious anaemia 
cells (Wesener). 



A, poikilocytes ; B, inicrocytes and granules ; C, eosinophile 



Deformity of corpuscles (poikilocytosis) is more marked than in 
any other affection. Elliptical, biscuit-shaped, bottle-shaped, reni- 
form, acuminate shapes appear in connection with very small and 
very large cells — microcytes, megalocytes. The microscope shows 
in the pernicious form nothing that may not be seen in other forms 
of anaemia ; but the fact that everything is so much more magnified 
and distinct is of itself characteristic. The red corpuscles no longer 
aggregate themselves like piled-up coin, but remain apart, scattered 
over the field. The white blood corpuscles are really reduced, but in 
so much less degree than the red as to appear to be increased — rela • 
tive leucocytosis. 

On account of imperfect nutrition, the heart's action becomes 



606 CHLOROSIS. 

weak ; attacks of palpitation occur often in the night. Dilatation 
of the right ventricle sets in, dulness extends beyond the right border 
of the sternum, the heart's apex is displaced to the left. Auscul- 
tation reveals a systolic murmur at the base. Anaemic murmurs 
are also audible over all the superficial vessels, which show visible 
pulsations. Hemorrhages are frequent from the various mucous 
membranes. Effusions in the brain may be fatal. Characteristic 
ophthalmoscopic pictures are furnished by effusions of blood into 
the retina. 

Though insidious in its onset, as the name indicates, the disease 
is progressive. The blood is robbed more and more of its essential 
constituents, the body suffers from lack of nutrition, the patient 
sinks from apathy into stupor, and death occurs suddenly as the 
result of haemorrhage, or more frequently in the course of a slowly 
progressive marasmus. 

Since the other signs are common to the various forms of 
anaemia, the diagnosis can be determined only by the condition of 
the blood. The important factor in diagnosis is the determination 
of the cause upon which the condition rests. Though occasional 
glands are swollen, the lymphatic system is not affected. 

The prognosis is exceedingly grave. The disease is usually, 
though not of necessity, fatal. 

The treatment is symptomatic, and, aside from discovery and 
treatment of the cause, does not differ from that of other forms of 
anaemia. In all cases of anaemia appeal should be made to the di- 
gestive apparatus to secure the absorption of wholesome food. It is 
sometimes wise to abandon all address to the blood and resort to the 
stomach tube, with daily irrigations, and to administration of dilute 
hydrochloric acid, gtt. x.-xv. largely diluted, before meals ; of 
tinctura nucis vomicae gtt. x.-xx., or tinctura rhei aromatica, tea- 
spoonful, diluted, after meals. The desperate case of Quincke re- 
ferred to, with a reduction of corpuscles to 143,000, recovered after 
the practice of transfusion. 

CHLOROSIS. 

Chlorosis {x^oopos, yellow-green). — A disease which occurs 
chiefly in girls at puberty, marked by anaemia which usually 
disappears under the use of iron. 

Etiology. — Chlorosis is almost limited to the female sex at the 
period of puberty. It has been exceptionally encountered in child- 
hood and maturity. A role of some importance in the causation of the 
disease is played by heredity, which Virchow explains as a congeni- 
tal hyperplasia of the vascular system. Other causative influences 
are emotional disturbances, home sickness, love sickness, bad habits, 



CHLOROSIS. 607 

night work, loss of sleep, onanism, premature pregnancy, lactation, 
certain infections, malaria, typhoid fever, etc. The chief cause of 
chlorosis is connected with some as yet inexplicable disturbance 
with ovulation. 

Symptoms. — The disease begins with a sense of growing weak- 
ness and easy fatigue. In fact, the feeling of fatigue is much 
greater in chlorosis, because of the great reduction of haemoglobin, 
than in any other form of anaemia, The tendency to sleep is irre- 
sistible. Some patients would, if permitted, remain in bed all day. 
Soon there is indifference; loss of interest; caprice regarding food, 
craving for indigestible, sometimes repulsive things (chalk, sand, 
slate pencils, mortar), which is secretly gratified ; constipation, 
flatulence, anorexia, dyspepsia, palpitation of the heart, headache, 
ringing in the ears, wandering pains. The skin and mucous mem- 
branes show a peculiar pallor, tinted with green, though the di- 
lated blood vessels of the cheeks often leave a red incarnation, the 
so-called chlorosis rubra, which may confuse the diagnosis (Weiss). 
Fluctuations of temperature, apparently without cause, dyspnoea, 
transitory oedema about the ankles and eyelids, occur, as in cases 
of other anaemia. 

The blood is pale, and, while the corpuscles are but little re- 
duced, the haemoglobin is reduced one-half, a disproportion char- 
acteristic of chlorotic blood. Alterations of form (poikiloeytosis) oc- 
cur in but slight degree. In consequence of defective nutrition the 
action of the heart becomes weak, the dulness is increased to be per- 
ceived beyond the right border of the sternum. Auscultation re- 
veals systolic murmurs, in the order of decreasing frequency, at 
the pulmonary, mitral, tricuspid, and aortic valves. Menstruation 
is disturbed in various ways. There is often amenorrhcea for months 
or years, sometimes metrorrhagia. 

Bleeding from the nose is not infrequent, is sometimes obstinate. 
Haemorrhage from the stomach depends upon ulcer, to which chlo- 
rotic patients are especially liable. 

The temperature is variously affected. Occasionally there is fe- 
ver without apparent cause. Sometimes the temperature is subnor- 
mal. Palpitation is frequent and is easily excited. The carotids 
throb in the neck, and murmurs {bruits de diable) are to be heard 
over the bulb of the jugular vein. Thrombosis may occur, espe- 
cially in the graver forms or after muscular strain. Rendu reported 
a fatal case from spontaneous thrombosis of the pulmonary artery. 
The respiratory organs are normal, but the respirations are in- 
creased in frequency, even during rest and sleep, because of the 
extra demand for blood, hematogenous insufficiency (Eichhorst). 
Xervous disturbances, infinite in variety, characterize chlorosis: 



608 LEUKJEklA. 

headache, insomnia, paraesthesiae, hyperesthesia, psychical altera- 
tions, caprice, incapacity, apathy, sometimes erotomania, kleptoma- 
nia, vary the scene. 

The diagnosis is often difficult at the start, for the gastrointes- 
tinal catarrh, headache, psychical alterations may precede the altera- 
tions in the blood and conceal the condition for a long time. The 
blood changes, when they appear, distinguish the disease from ordi- 
nary anaemia. Chlorosis is distinguished from pernicious anaemia by 
the prompt effect of treatment, and from the oedema of nephritis by 
the examination of the urine. Tuberculosis must always be elimi- 
nated by careful observation of temperature, the use of tuberculin, 
examination of the sputum and of the chest. Ulcer of the stomach, 
in the absence of haemorrhage, may be diagnosticated by hyper- 
acidity, as revealed by the stomach tube, which is often used in the 
treatment of the gastro-intestinal complications of chlorosis. 

The treatment consists in the use of iron. The materia medica 
is rich in preparations. The saccharated carbonate may be admin- 
istered in doses of gr. xxx.-xl. a day, or the ferrum redactum, in 
pills, gr. x.-xv. a day. The compound mixture is an efficacious 
preparation, which may be substituted by the compound pill of iron. 
A combination of iron with a few drops of Fowler's solution of arse- 
nic is often advantageous. The pill of aloes and iron obviates consti- 
pation. The stomach may be toned and stimulated by hydrochloric 
acid, gtt. x.-xx. in a wineglass of cold water, before meals, and some 
bitter infusion, condurango, calumbo, absinth, or tinctura rhei aro- 
matica, 3ss.-3i. in a dessert- to a tablespoonful of water, after 
meals. Constipation may be relieved by tamarinds or by cascara 
in cordial or tablet form. Sometimes it is wise, on account of the 
condition of the stomach, to abandon all specific treatment for a 
time and address the stomach directly by irrigation with the stomach 
tube. 

LEUKEMIA. 

Leukaemia (XevkoS, pale, aijia, blood) ; leucocythaemia. — A dis- 
ease characterized by reduction of both red and white blood corpus- 
cles, with the general signs of anaemia. Virchow (1845) first distin- 
guished the affection as a separate disease dependent upon the 
relative increase of the white blood corpuscles. The normal propor- 
tion of white to red corpuscles is 1 : 300 or 1 : 400. Leukaemia may 
show in a light case a ratio of 1 : 40 or 1 : 30 ; in a marked case, 1 : 10 
or 1 : 5 ; in the worst cases, 1 : 2 or even 1:1. 

Leukaemia leads always to enlargement of the blood-making or- 
gans, especially to the organs which stand in close connection with 
the white blood corpuscles, the spleen, the lymph glands, and the 
marrow of bones. The increase in size depends upon hyperplasia. 



LEUKEMIA. 



609 



It is sometimes very extensive. The spleen may reach to the umbili- 
cus; the lymph glands form tumors in the neck, axilla, and groins, 
as large as an egg; the medulla may actually distend and disrupt 
bones. The attempt has been made to distinguish forms as lienal, 
lymphatic, and medullary, according as affection of one or the other 
organ or tissue assumed prominence. But mixed forms are so com- 
mon as to invalidate conclusions. Other organs besides those men- 
tioned, the liver, kidneys, skin, mucous and serous membranes, 
undergo hyperplasia or contain secondary deposits. 

Etiology. — The cause of the condition is unknown. The disease 
is more frequent in men, and between the ages of thirty and fifty, 
though it has been observed in children. Leukaemia has been found 
to develop after malaria, syphilis, tuberculosis, rickets, under depress- 
ing mental emotions — anxiety, ap- 
prehension, grief— and in the 
course of exhausting discharges. 
Sometimes it develops without 
discoverable cause. The disease 
is regarded as a chronic infec- 
tion from unknown cause. 

Symptoms. — The symptoms 
are the same as those already de- 
scribed in connection with other 
forms of anaemia. There arepal- 
lor of the skin and mucous mem- 
branes, palpitation of the heart 
with the development of mur- 
murs, shortness of breath upon the slightest exercise, early fatigue, 
alterations of disposition, disturbances of vision, fever without ap- 
parent cause, epistaxis and other haemorrhages. In the course of 
time the disease, which has expended its main force in one or the 
other of the various organs — the spleen, the lymph glands, and the 
bone marrow — extends to involve other organs, so that leukaemia is 
progressive. 

The diagnosis is not difficult. The signs of anaemia are attended 
with distinct enlargement of the spleen and lymph glands. In ad- 
vanced cases the most superficial observation shows the disproportion 
between the white and red blood corpuscles. The Charcot crystals, 
described with the sputum of asthma, are found free in the serum 
and incorporated in the white blood corpuscles. They are most 
abundant in the bone marrow, and may be seen in blood freshly 
drawn from the spleen. Leukaemia is distinguished from leuco- 
cytosis by the progressive character of leukaemia. The presence of 
eosinophile cells speaks in favor of leukaemia. 




Fig. 259.— The blood in leukaemia, showing the 
disproportion of the white and red corpuscles. 
Nummulation perfect. 



610 PSEUDO-LEUKEMIA. 

The prognosis is very grave. The tendency is progressively 
downward. 

Treatment is almost hopeless. Quinine in large doses sometimes 
arrests the progress of the disease, more especially in the beginning. 
Arsenic has no effect upon it. Local treatment of the spleen is of 
no value. Extirpation of the spleen only aggravates the condition. 
Mosler, who had a large experience with leukaemia, recommended 
quinine, piperin, and the oil of eucalyptus in its treatment. Thus : 

? Quinism hydrochloratis 2.0 

Piperini 5.0 

Olei eucalypti e foliis 10 

Cerse alba? , 6.0 

M. Fiat pilulse No. 100. S. Three pills two or three times a day. 

Hoffmann saw no good from inhalations of oxygen, but found 



1 
W 

m -M. 

mmmBmsmmms 

?mmmmmxmm» 



m 



"'? Fig. 260.— Hypertrophy of spleen in lienal lymphatic leukaemia: a, white lymph nodules; b, 
yellow ischsemic infarct. Natural size, child. 

virtue in douches and cold frictions over the spleen. Mosler recom- 
mends „ : transfusion. Surgical intervention is absolutely to be con- 
demned, as of twenty cases of extirpation of the spleen but one 
escaped with life. 

Pseudo-leukaemia, anaemia splenica, Hodgkin's disease, is a 
sub-variety of leukaemia, distinguished by enlargement of the spleen 
and lymph glands, without, or with but slight, increase of the white 
blood corpuscles. The disease is essentially the same, save that the 
progress is much less rapid, arrest with temporary improvement, and 
actually recovery, more frequent. 

The treatment does not differ from that of leukaemia. It is 
claimed that the injection of arsenic into the substance of the spleen 
and lymph glands is sometimes of value. 



THE HEMORRHAGIC DIATHESIS. 611 



THE HEMORRHAGIC DIATHESIS. 



The haemorrhagic diathesis is a disposition to haemorrhage from 
capillaries (per diapedesin) or from larger vessels (per rhexin). The 
haemorrhage occurs in consequence of trivial accident, break of 
vessel, or spontaneously without any trauma whatever. The blood 
escapes with all its elements through rupture of vessels or paretic 
vessel walls, or by reason of the disintegration of the blood ; or 
haemoglobin, liberated from the corpuscles and held in solution in the 
serum, escapes from the blood vessels, especially in the kidneys, to 
constitute haemogiobinuria. The diathesis is, as the term applies, 
general, so that haemorrhage may occur from any surface. Bleeding 
from the nose, epistaxis, is most frequent. It occurs spontaneously 
— i.e., without apparent provocation — is profuse, intractable, occa- 
sionally fatal. Sometimes the disposition is local, in which case it 
shows itself usually only in the nose; next most frequently in the 
intestine. Bleeding may likewise occur from any mucous mem- 
brane, from the mouth, nose, lungs, from the intestine, bladder, 
uterus. Haemorrhage may take place also into the various serous 
membranes and internal organs, including the brain. It shows itself 
frequently upon the surface in the form of petechia?, ecchymoses, 
vibices. 

Here belong also the cases of haemathidrosis, or sweating of 
blood — a condition which may not be denied, since blood corpuscles 
have been found in the ducts of sweat glands with an unbroken skin 
(Tittel), and the celebrated cases of stigmatism, or bleeding from a 
sound skin, which Lefebvre alone has actually seen. 

The haemorrhagic diathesis is sometimes inherited, but is usually 
acquired. When inherited it must be distinguished from haemo- 
philia, which is transmitted only in certain directions. More fre- 
quently the condition is acquired. It shows itself as a sequel to some 
infection, especially to typhoid fever and small-pox, more infre- 
quently to yellow fever, septicaemia, diphtheria. It belongs to the 
graver forms of anaemia. 

The prognosis is serious. Life is usually cut short by haemor- 
rhage from or in some inaccessible region. 

The treatment consists in the administration of iron, the tincture 
of the chloride gtt. xx.-xl., largely diluted; acids, hydrochloric acid 
gtt. xij.-xv., largely diluted; the tincture of cinchona 3 i-— ij. four 
times a day; the syrup of the hypophosphites in like quantity. The 
nutrition is to be improved, especially by food and fresh air. Haem- 
orrhage is controlled by rest, the application of ice, the use of tam- 
pons. As haemorrhage from the nose usually occurs from the sep- 
tum, it may be often stilled by the deep insertion of a roll of cotton 



612 PURPURA. 

upon a small sound. Aggravated cases necessitate the use of the 
tampon, introduced by a canula. Internal hemorrhage calls for the 
use of opium, atropine, acetate of lead, digitalis, the subcutaneous 
injection of ergotin or sclerotinic acid. 

H^emoglobinemia occurs in the form of (1) Paroxysmal 
Hemoglobinuria of adults, characterized by periodical attacks of 
fever, with nervous disturbance and the appearance of urine stained 
red with the coloring matter, but free, or almost free, of the corpus- 
cular elements of the blood ; and (2) Congenital Hemoglobinuria, 
which shows itself in the new-born child, usually about the fourth 
day, with vomiting and diarrhoea, icterus, cyanosis, and urine stained 
with the coloring matter of the blood. Some of the cases undoubt- 
edly belong to the disease generally described as icterus neonatorum. 

PURPURA. 

Purpura; morbus maculosis (Werlhof). — The condition appears in 
two forms, as purpura simplex and purpura hemorrhagica. 

Purpura simplex is a hemorrhagic diathesis limited to certain 
parts of the body, especially to the lower extremities, of little or no 
gravity. It shows itself most frequently on the legs as petechia?, 
which sometimes unite to form larger exudations, ecchymoses. Pur- 
pura is observed occasionally in the course of the graver infections, 
especially in patients who get about too soon. More commonly the 
disease is spontaneous, occurring often without known cause in the 
midst of apparent health. It shows itself more frequently in the 
young, and rather more frequently in women. Subjects of it are 
liable to frequent attacks. The outbreak is sometimes preceded by 
light fever. The spots usually fade away gradually and disappear 
in the course of a week or ten days. 

Purpura hemorrhagica is the graver form, found in connec- 
tion with haemorrhage elsewhere, as with epistaxis, hematemesis, 
hematuria, sometimes with evidences of hemorrhage of serous mem- 
branes and internal organs. Both forms may be attended with pain 
in the joints — purpura rheumatica. Where the joint affection as- 
sumes prominence the disease is sometimes distinguished as peliosis 
rheumatica (nsXios, black and blue). The possible existence of en- 
docarditis (embolus) must not be overlooked in these cases. Certain 
snake bites produce a typical purpura. 

The prognosis of purpura simplex is favorable, of purpura 
hemorrhagica exceedingly grave. Purpura hemorrhagica occurs in 
a fatal form of variola, the so-called purpura variolosa. 

The treatment does not differ from that of general hemorrhagic 
diathesis. 



HEMOPHILIA. 613 



HEMOPHILIA. 



Haemophilia is a hemorrhagic diathesis which is transmitted by 
heredity. 

History. — -The condition was first described by an Arabian phy- 
sician. Alsaharavi, Cordova (a.d. 1100). who recognized it as a dis- 
position to obstinate and uncontrollable haemorrhage in the males of 
certain families. With the exception of isolated cases by Benedic- 
tus (1525), Hoerchstetter (1635), published by Virchow, and a third 
by Banyer (1713), the disease is not further mentioned in medical 
history until by Otto, of New York, in the record of a bleeder family 
in which the disease could be traced back for nearly a hundred years. 
Other cases of families similarly affected were soon reported in this 
country. Nasse published the first monograph in 1820. Grandidier 
succeeded in collecting six hundred and fifty authenticated cases in 
two hundred §nd nineteen families up to 1872. 

Etiology. — The disease is transmitted chiefly by mothers to sons, 
in whom the fully developed form is twelve times more frequent 
than in daughters. Males who are thus bleeders do not, as a rule, 
transmit the disease ; but females, the offspring of bleeder families, 
without being themselves bleeders, beget children some of whom 
suffer or show pronounced haemophilia. Various causes have been 
assigned for this condition— lack of fibrin or of fibrinogenous elements, 
superficial and vulnerable course of blood vessels, thin walls of ves- 
sels, etc. Nothing definite is known. 

Symptoms. — The condition is usually accidentally discovered : a 
trivial lesion is followed by profuse, protracted, sometimes uncon- 
trollable haemorrhage. The scratch of a pin, the extraction of a 
tooth, the operation of circumcision, the application of a leech, vac- 
cination, excite a dangerous haemorrhage. 

Diagnosis. — Haemophilia is distinguished from the haemorrhagic 
diathesis by the fact that it is hereditary, that it occurs in the male 
child, or that in either sex it has been observed in the earlier years 
of life. Spontaneous haemorrhage is much more frequent in the 
haemorrhagic diathesis. 

The prognosis is grave. In most cases life is cut short by un- 
controllable haemorrhage. 

The treatment consists, essentially, in prophylaxis, in the avoid- 
ance of accidents, operations, etc. Surface haemorrhage may be 
controlled by compression, which must be unusually long sustained. 
Haemorrhage from the nose ma}' be checked by the tampon; haemor- 
rhage from the lungs by the subcutaneous injection of ergotin or 
sclerotinic acid: haemorrhage from the bowels by the acetate of lead, 
half a grain to a grain every two hours ; haemorrhage from the ute- 



614 SCORBUTUS. 

rus is best controlled by the insertion of tampons of iodoform gauze; 
haemorrhage from the mucous membranes and internal organs by the 
use of cold and styptics, ice, iron, iodoform. Manteuffel declares 
that the parenchymatous injection of a solution of cocaine, 0.5 per 
cent, into the gums will always temporarily arrest hemorrhage from 
this source by contracting blood vessels, and that the application of 
what he calls zymoplastic matter, a substance derived from the blood 
itself, will arrest it more permanently. The nutrition is to be im- 
proved in every way with cod-liver oil and iron, food and fresh air. 

SCORBUTUS. 

Scorbutus (low Latin) ; scurvy (from scurf). — A general disease, 
characterized by cachexia, characteristic affection of the gums, hsem- 
orrhagic diathesis, and marasmus. Scurvy is a disease which stands 
in close relation to the character of the food, especially with the ab- 
sence of fresh and vegetable food. Improvement in#the conserva- 
tion and transportation of foods has led largely to its extinction. 
The disease prevailed in epidemic form from the fifteenth to the 
eighteenth centuries and in special severity in prisons, workhouses,, 
and barracks. Scurvy was a constant disease of sea life ; a very 
long voyage was attended with the loss of a number of men. The 
disease still prevails under similar conditions, as in Paris during the 
siege of 1870 and 1871, where scurvy assumed epidemic proportions. 

Etiology. — Scurvy is distinctly connected with defective nutri- 
tion, whether in quantity or quality, though the exact relationship 
of this factor has not yet been established. Crowd poisoning, ex- 
haustion, anxiety, nostalgia, cold, lack of sunlight, haemorrhage, 
chronic disease, malaria, tuberculosis, gastric catarrh, anything 
which tends toward inanition, predisposes to the disease. Scurvy 
is probably an infection, but there is as yet no other proof for this 
statement than the character of the symptoms. 

Symptoms. — Scurvy begins with debility, which manifests itself 
in early fatigue, rheumatic pains in the loins and legs, and is soon 
associated with the pallor and depression of spirits which belong to 
a cachexia. Scurvy may not be distinguished in this regard from 
other cachexias until a characteristic appearance shows itself in the 
mouth. The gums are sivollen by infiltration with serum and blood. 
The color changes from red to dark blue ; the spongy tissue easily 
bleeds, and the loss of substance shows ulceration and necrosis, some- 
times with deep destruction of tissue. The surface is covered with 
debris and detritus of excessively fetid odor. The breath is defiled. 
The swelling of the gum confines itself to the region of the teeth. 
Toothless places remain unaffected. Scurvy soon shows the imprint 
of the general hemorrhagic diathesis. Spots of haemorrhage, pe- 



SCORBUTUS. 615 

techiae, purpura, appear upon the skin, sometimes as papules, lichen 
scorbuticus, vesicles, bullae, pemphigus or linear streaks, vibices. 
Extravasations occur also in the deeper structures, especially in the 
lower extremities at seats of pressure or injury. Free haemorrhage 
occurs from the various mucosae, from the nose, bronchi, stomach, 
intestines, bladder, etc. The serous membranes are likewise at- 
tacked. Extravasation occurs in the pleura, pericardium, into the 
joints, and the various inflammations which may occur show a haem- 
orrhagic character. Tissues thus infiltrated are easily broken down 
to suffer extensive ulceration and destruction. As the general weak- 
ness increases the action of the heart is weakened, its diameters are 
increased, and systolic murmurs may be heard at the base. The 
pulse becomes frequent and feeble. (Edema develops at the ankles. 
Attacks of syncope are common. 

The diagnosis rests upon the history of a cause, upon the cachexia 
and haeraorrhagic diathesis, but is really determined by the pecu- 
liar condition of the gums. 

The prognosis is always serious, and depends largely upon the 
strength of the individual, the surroundings of the patient, and the 
stage of the disease. It is more favorable at sea because of the 
fresh air, at least. 

Treatment. — The better means of food supply shows its effect in 
the diminution of scurvy, which is on the road to extinction. The 
treatment is a continuance of the means of prophylaxis — viz. , the 
administration of an abundance of fresh food, and especially vegeta- 
ble food : fruits — oranges, lemons, apples, etc.; vegetables — onions, 
lettuce, radishes, cabbage, sauerkraut, spinach ; greens — dandelions, 
etc. Fresh meat itself may be transported packed in ice or may be 
substituted by the various extracts of beef. The mouth must be 
disinfected with washes of peroxide of hydrogen, creolin, one-half of 
one per cent solution, and the spongy gums directly treated with so- 
lutions of nitrate of silver one per ' cent, tannin in some form, as 
in the tincture of kino, catechu, preferably the tincture of myrrh. 
A fine remedy for protection and preservation of the teeth is the 
preparation of thymol devised by Thomas. The mouth should be 
first thoroughly washed with soap, with care that the brush pene- 
trate to all crevices of the teeth, and thereupon with the following 
solution : 

R Thymol 0.25 

Acidi benzoici 3.00 

Tincturae eucalypti.. 15.00 

Alcohol 100.00 

Spiritus menthae piperitae 0.75 

M. Add a sufficient quantity to a glass of water to make it milky. S. Use twice 
a day. 



616 MORBUS ADDISONII. 

This preparation kills all bacteria of the mouth within one minute. 
The mouth should also be rinsed out with a three-per-cent boric- 
acid solution after each meal. 

Thymol is the best remedy in the treatment of a sensitive pulp 
cavity from any cause, or in any kind of caries, and is destined soon 
to substitute the dangerous arsenical pastes. 

The aniline preparations, methylene blue 1 : 100, penetrate deeply 
and purify. The strength must be supported by the judicious use 
of stimulants, the appetite increased by dilute hydrochloric acid gtt. 
xij.-xv. in a wineglass of water, dilute phosphoric acid gtt. xv.-xxx., 
mix vomica gtt. x.-xx. in a tablespoonful of water. The maras- 
mus is met by malt extracts, especially incorporating cod-liver oil ten 
to forty per cent. 

MORBUS ADDISONII. 

Addison's disease ; Bronze Skin disease. — An affection of the 
suprarenal capsules, distinguished by a peculiar discoloration of the 
skin, progressive cachexia, and marasmus. 

History. — Schotte (1823) and Bright (1831) reported cases of this 
affection, which were, however, only distinctly separated by Addi- 
son (1855). Ranking and Taylor (1856) reported the first cases in 
this country. 

Etiology. — The disease is rare. Males are twice as frequent 
subjects. The majority of cases occur between the ages of twenty 
and forty. It has been noticed to follow injuries. The cause is 
assumed to be a degeneration of the suprarenal capsules, which 
may be independent as a fibroid change, but is more frequently 
dependent upon tuberculosis as a caseous change. The condition of 
the suprarenal capsules has been also considered as an effect of 
disease of nerve ganglia, especially the plexus cceliacus. In certain 
cases the suprarenal capsules have been found to be affected with 
carcinoma. 

Symptoms. — The disease is said to stand upon a tripod of symp- 
toms—to wit, discoloration of the skin, progressive ance?nia, and 
degeneration of the suprarenal capsules. Any one of these con- 
ditions may be present or absent in certain cases. Addison associ- 
ated with these symptoms general languor and debility, feebleness of 
the heart's action, and irritability of the stomach. The discoloration 
assumes a bronze, that is, a greenish-broivn, tint, but varies in shade 
from light yellow to dark brown or black. The pigment is deposited 
in the deeper layers of the rete Malpighi. Sometimes it is diffused, 
but is usually most marked on the surfaces naturally most deeply 
pigmented — nipples, scrotum, penis. For obvious reasons it is first 
seen in the face. The various mucosae are also discolored; spots are 



MORBUS ADDISONII. 617 

seen upon the lips and cheeks. The vagina is often deeplj T tinged. The 
serous membranes have been found bronzed. The sclera usually es- 
capes. The bed of the nails remains white. The discoloration usually 
comes on later in the history of the disease, and is preceded by a 
period of debility. Anaemia and cachexia gradually develop, usually 
without much loss of flesh, and in association with them anasarca, 
dyspepsia, g astro-intestinal catarrh. Rheumatoid pains are fre- 
quent. Symptoms on the part of the nervous system are prominent. 
Languor increases to depression; in the later period of the disease 
there are sopor, delirium, convulsions, and coma. Patients succumb 
slowly to marasmus, sometimes suddenly to heart failure. 

The pathogeny is obscure. All attempts to locate the origin of 
the disease in the suprarenal capsules would seem to have been nul- 
lified by the experiments of Nothnagel, who found no changes in one 
hundred and fifty-three animals after total extirpation of these 
bodies. On the other hand, Lewin found actual tuberculosis of the 
adrenals in two hundred and *eighty-five of three hundred and 
seventy cases, and in the remaining eighty-five cases no disease of 
these organs It is therefore not improbable that other affections 
have been included under the term Addison's disease, and that the 
malady pur et simple is, as Addison declared, a degeneration of 
these bodies. Brown- Sequard long ago ascribed to the suprarenal 
bodies the function of converting pigment into colorless matter. 
The failure of the symptoms after extirpation of the adrenals may 
be explained by the fact that the animals were not kept long 
enough, as Tizzoni found that in rabbits kept alive two and three- 
quarter years after crushing of the adrenals similar pathological 
pigmentation developed with multiple degenerations in the spinal 
cord. 

The diagnosis rests upon the train of symptoms mentioned: the 
asthenia, discoloration, gastro-intestinal catarrh, progressive cachex- 
ia, anaemia, and marasmus. The presence of no single factor, not 
even the discoloration of the skin, is necessary to a diagnosis. The 
disease must be distinguished from the discolorations caused by 
tumors in the abdomen, pregnancy, disease of the uterus and liver, 
chloasmata, as well as from that deposit of pigment which occurs in 
connection with pediculosis and from the peculiar discoloration of 
nitrate of silver. The lack of associate symptoms suffices to make a 
diagnosis. 

The prognosis is fatal. The disease lasts from a few weeks to 
several years. The average duration of life is a year and a half. 
The course is longer, and to this extent the aspect more favorable, in 
cases where the bronze discoloration is most pronounced. Recov- 
eries are considered proofs of mistake in diagnosis. 



618 GOUT. 

The treatment does not differ in any way from that of anaemia 
and cachexia from other cause. Rest of body and peace of mind, 
with favorable hygienic surroundings, may materially prolong life. 

GOUT. 

Gout (gutta, a drop). — A disease caused by the instillation into 
the joints of uric acid ; characterized by pain in paroxysms — first in 
the big toe, later in other joints— later by deformities of the joints, 
affection of the heart and kidneys (atheroma), and marasmus. 

History. — Gout is a disease of ancient recognition, though the 
term itself is comparatively modern. It was known at the time of 
Hippocrates as "podagra," and prevailed with such frequency in 
the opulent days of, Rome as to have attacked women as well as 
men. Lucien named one of his characters Podagra. The term 
gout dates from the days of humoral pathology. It has an origin 
of the same significance as rheumatism and catarrh, in that the 
peccant humors which float about in the blood come to be distilled, 
drop by drop (guttatim, gutta, a drop), into the joints. 

However much our views of disease processes have changed 
since the days of humoral pathology, gout still holds its place as the 
distillation of an acrid humor from the blood. While all the other 
diatheses have failed and fallen to the ground, the gouty diathesis 
remains. An increase of uric acid in the blood, a deposit of uric 
acid in the joints, from kidney fault (Garrod), from local cause 
(Ebstein), constitutes the pathology of gout. This discovery, due to 
Wollaston (1798), constitutes the keystone of our knowledge regard- 
ing gout. All other theories must conform to this central fact. It 
was Sydenham who first separated gout from the rheumatisms. The 
graphic descriptions of Sydenham were founded upon not only per- 
sonal observation, but personal experience ; and the fact was noticed 
by him as a matter of comfort that individuals of the upper rather 
than the lower class are the victims of this disease. " Great kings, 
emperors, generals, admirals, and philosophers have all died of 
gout," which, ''unlike any other disease, kills more rich men than 
poor, more wise men than simple." In our day this fact is a poor 
consolation, for it is, as Fagge says, robbed of its virtue, because 
life-insurance examiners put a higher premium upon, or absolutely 
refuse insurance on, the lives of gouty patients. 

Etiology. — Gout occurs for the most part in the latter period of 
life, with increasing frequency from forty to sixty ; exceptional 
cases at sixteen and eighteen have been put upon record, such cases 
also at eighty, but the disease rarely originates after sixty-five. 
Cases in advanced life are survivals. Gout is a hereditary disease. 
Statistics of the most competent observers — Garrod, Scudamore — put 



GOUT. 619 

the proportion at from one-third to one-half. It has been remarked 
that the eldest members of the family suffer more uniformly and 
more severely, as the younger members, observers of the sufferings 
of the disease, refrain from excitants to some extent. 

Gout is a disease of high livers, of rich animal food with abun- 
dant libations of alcohol, of food more especially which is highly 
seasoned, of wines with rich aroma. So gout may attack the young. 
It may also attack those who are more advanced in age, even 
though of abstemious habit, through heredity— sometimes as the 
only inheritance, the fortune having been spent in its acquisition. 
Workers in lead, more especially plumbers, painters, and printers,, 
are predisposed to gout. 

Uric acid injected into the blood in health is speedily converted 
into urea and eliminated. The excretion of uric acid varies in health 
between three and fifteen grains per day, and is subject to much 
greater variation with changes in diet, exercise, etc. It is therefore 
difficult to establish estimates of quantities which will produce dis- 
ease. Nevertheless Pfeiffer ascertained by careful measurements, 
taken with every possible precaution, that patients with acute gout 
excrete more, and patients with chronic gout less, uric acid than in 
health. Rich foods, especially the albuminates, in excess, overload 
the blood with acids and diminish its alkalescence, a condition which 
favors the conversion of the urates into urea. 

Symptoms. — The attack occurs for the most part suddenly. The 
patient retires in his usual health, sometimes with exaltation of 
spirits, more frequently with more or less depression, the result of 
dyspepsia with its train of distress, and is awakened in the night, 
between midnight and morning, with pain localized, as a rule, in 
the big toe joint. The pain is at first an uneasiness, soreness ; the 
patient moves his foot about, extends it, withdraws it, protrudes it, 
in the vain effort of seeking a comfortable position. Sometimes 
there is a feeling as if tepid water were poured over the joint. 
There is no finding a comfortable position. The pain increases, be- 
comes excruciating ; the patient feels as if the joint were penetrated 
with hot irons, were twisted, crushed in a vise. The slightest agi- 
tation of the room or of the bed, the rumble in the streets, exaggerates 
it and irritates the patient beyond expression. In the course of half 
an hour to two hours the pain begins to diminish, sometimes with 
diaphoresis, sometimes with diuresis. The patient begins to feel 
that he has at last found a comfortable position, the pain dies away, 
the patient falls asleep, to be awakened in the morning, after rather 
protracted sleep, entirely, or almost entirely, free of pain. On in- 
spection of the joint it is seen now to be reddened, sivollen, tender, 
limited in its movements. The skin pits upon pressure. The patient 



620 



GOUT. 



is able to resume his avocation. On the following night the whole 
condition may reappear, or not for several nights, or a fortnight, 
sometimes not for months or a year. The interval will depend 
largely upon the habits, especially regarding self-denial. As a rule 
the first interval is the longer. The patient profits by the first les- 
son for a time until indulgence renews the attack. The disease now 
extends to involve other toes, to affect also the joints of the fingers, 
to extend afterward to the ankles and wrists ; but in however great 
extent or severity, it never, or almost never, affects the largest joints, 
the hip and shoulder. As the disease repeats itself more frequently, 
the attacks become comparatively milder. The interval grows 
shorter, but the individual attacks are longer. Finally the inflam- 
mation about the joints never does entirely subside. Characteristic 
deformities supervene, and with these deformities are associated 
chronic gastric catarrh with its attendant evils, affections of the 
kidneys, atheromatous changes, functional and organic heart 




Fig. 261.— Gouty fingers. 



affections. The patient now becomes more or less emaciated, irri- 
table, morose. On the other hand, in some cases the bien-etre re- 
mains. The florid face from paretic capillaries or acne rosacea, the 
sluggish circulation, the dull expression, indicate the addiction to 
high living with its corresponding degradations. 

Cases of chronic gout present characteristic deformities about 
the joints. The swelling of the acute attacks subsides often to 
leave no trace, but as the disease becomes more and more chronic 
the swelling does not entirely subside ; it abates, but does not dis- 
appear. The fluctuation gives place to a doughy sensation, the 
matter instilled into the joint becomes thicker and thicker as its fluid 
elements are absorbed. It becomes also more irritating, breaks the 
skin, at times to show an ulcer or an abscess from whose surface or 
interior oozes a substance of mortar-like consistence, composed 
almost exclusively of the urate of sodium. These ulcers are exceed- 
ingly refractory. They continue to discharge, with quiescent inter- 
vals at times, for months or years or for the life of the patient. 



GOUT. 



621 



As a result of the depositions of this salt into the joint the articu- 
lating surfaces are deformed, the joint becomes dislocated; various 
anomalous positions are thus assumed. A common habitus is that 
of forcible flexion of the fingers at the second or third joint, with 
exception of the first. The first knuckle is represented by a depres- 
sion. Sydenham says the fingers look like a bunch of parsnips. The 
same alterations occur about the feet, about the toes, and deformities 
of the wrist and ankles may incapacitate the individual for the needs 
of life. These tophi, erroneously called chalk stones, occur also, as 
stated, in any joint distant from the 
circulation, about the ear, and va- 
rious portions of the skin, at any 
one of which an ulcer may form. 

Diagnosis. — The tendency to 
gout is indicated by dyspeptic states, 
pressure at the prsecordium, palpi- 
tation, numbness of the extremities, 
with itching and eczema of the skin, 
neuralgias or pains anywhere, mi- 
graine, insomnia, asthmatic attacks. 
The sudden occurrence of conjunc- 
tivitis, iritis, or corneal ulcer be- 
tokens attack in some people, and 
hitherto inexplicable cases of any of 
these affections become not only in- 
telligible but curable when inter- 
preted as premonitions or prodro- 
mata of gout. 

Gout is distinguished from arti- 
cular rheumatism by the fact that 
it attacks age rather than youth. 
The history of heredity and high 1 
living gives some help. The char- 
acter of the onset in one joint, especially the big toe joint, is very 
different from that of implication of multiple joints, more especially 
medium-sized joints, of acute rheumatism. Gout remains fixed; rheu- 
matism flies from joint to joint. Rheumatism is a disease of inde- 
finite but of shorter duration ; gout is for the most part a lifetime 
malady. Gout shows much less fever, and the fever in gout is more 
directly proportionate to the extent of the local inflammation ; where- 
as there may be in rheumatism much fever with little inflammation, 
or much inflammation with but little fever. Gout is more especially 
attended by gastric disturbance; in rheumatism there may not even 
be anorexia. Gout affects the kidneys and heart with cirrhotic and 




Fig 



Tophi in the joints and tendons. 



622 GOUT. 

atheromatous change ; rheumatism affects the serous membranes. 
Rheumatism yields more readily to treatment, gout more readily to 
diet and regimen. 

Gout distinguishes itself from chronic rheumatism by the fact 
that gout affects small joints, chronic rheumatism large joints. 
Chronic rheumatism shows no fever and is unattended with any 
cardiac or renal changes. Chronic rheumatism is more unamenable 
than gout to treatment. 

The disease which is most frequently confounded with gout is 
arthritis deformans. The following points draw the lines of distinc- 
tion: Gout affects most frequently males, arthritis females. Gout 
chiefly affects the upper, arthritis the lower classes. Gout begins in 
the toes, arthritis in the fingers. Gout swells and dislocates the 
joints of the big toe and afterward of the other toes. Arthritis com- 
mences by preference in the fingers, which it also swells and dislo- 
cates, as a rule in a more regular way, so as to imbricate the joints 
of the first three fingers, pointing the fingers toward the ulna. 
Gout, when it affects the hand, does not to the degree of arthritis 
spare the thumb. The deformities of arthritis are produced by out- 
growths of bone; of gout by deposits of sodium urate. So-called 
cases of rheumatic gout are supposed to represent mixed forms or 
coincident attacks. The possibility of such a condition may not be 
denied, but an autopsy decides always in favor of one or the other. 
In a doubtful case the blood may be examined for urate of sodium. 
If two drachms of blood serum be slightly acidulated with acetic acid 
in a watch glass and a linen thread be suspended or laid across the 
glass, the thread will be fouiid after twenty-four hours covered with 
crystals of uric acid. Uric acid may also be crystallized out of the 
fluid of a blister not too near the joint. It is needless to say that this 
excess of uric acid cannot be detected in rheumatism in any form or 
in arthritis deformans. It belongs exclusively to gout. 

Prognosis. — Gout is in itself not especially dangerous. It is 
dangerous only in the remote consequences which its persistence 
may entail. All cases of acute gout recover, and the future of the 
case depends largely upon the habits of the individual. On the other 
hand, where the hereditary taint is strong or the conditions of life 
exclude proper hygiene, where gout becomes chronic, the duration of 
life is abbreviated by disease of the kidneys, heart, or brain. It may 
be said, therefore, that the prognosis of acute gout is good, of chronic 
gout is bad. 

The treatment depends, first, upon the regulation of life. The 
sedentary avocation must be changed; the gouty patient should 
walk, or, better, should ride horseback. Conditions which tend to 
obesity, sluggishness of circulation, constipation, must be overcome. 



ARTHRITIS DEFORMANS. 62 



The diet should be simple, plain, and homely food. Meat should be 
taken but once a day, vegetables without rich sauces. Alcohol must 
be put under ban. The time may come in chronic gout when a glass 
of Rhine wine or claret may be necessary, but as a rule the best 
drinks are water and milk. Sydenham lamented that he might not 
live to witness the discovery of a specific for gout. Not many years 
after his death a remedy was sold, under the name of Eau Medicinal, 
which proved of such virtue as to seem almost specific. The active 
principle of this remedy was discovered to be colchicum, meadow 
saffron; and colchicum in its alcoholic preparations soon came into 
general use in the treatment of gout. Watson vaunted its virtue. 
The remedy was given as the wine of colchicum, gtt. x.-xl. two or 
three times a day, in association with or followed by a saline laxative. 
Mineral waters — the alkaline mineral waters — largely aid the 
treatment, and sometimes suffice to make a cure without colchicum. 
The waters of Vichy and Carlsbad, and waters containing lithia, are 
of especial value. The ordinary Carlsbad salts, containing large 
quantities of the sodium phosphate, are a remedy justly in general 
use. A glass of cold water containing *i teaspoonful of this salt is 
taken three or four times a day. After the discovery of the salicy- 
lates it was soon found that these preparations had all the virtues 
without the vices of colchicum. Colchicum in a dose too large, or 
in a stomach too irritable, produces nausea, vomiting, diarrhoea. 
The salicylates are not attended with these evils, and choice may be 
had, with reference to the condition of the stomach, of the salicylate 
of soda, salicin, or salol. Piperazin is a powerful solvent. It dis- 
solves twelve to fifteen times as much uric acid as lithia. It is given 
best in tablets, fifteen grains per day, or in large quantities of water 
(soda water, Vichy, etc.), always in itself a valuable adjuvant. It 
is especially indicated in cases complicated with gravel or kidney 
stone. A good fluid preparation is: 

R Piperazini puri , gr. xv. 

Syrupi aurantii corticis 3 v. 

Aquas dt-stillatse 3 v. 

M. S. The whole quantity to be taken during the day. 

The remedy is not injurious in any way in twice or thrice the dose. 

Envelop the joints in cotton. All other local treatment is useless. 
Energetic patients cut an attack short by getting out of bed and 
going about as soon as possible. 

ARTHRITIS DEFORMANS. 

Arthritis deformans ; rheumatic gout ; nodular rheumatism ; ar- 
thritis sicca ; arthritis pauperum; poly panarthritis. — A disease char- 
acterized by progressive, symmetrical deformity of the joints. 



624 ARTHRITIS DEFORMANS. 

History. — Arthritis deformans existed from the most remote an- 
tiquity. Chiaje, of Naples, saw the deformities in bones exhumed 
from Pompeii. Lebert described the same changes in skeletons found 
in the catacombs of Rome, and Virchow in the joints of bodies dug 
up in an ancient monastery of Pomerania. The old writers consid- 
ered it simply a form of rheumatism, and Sydenham, who sepa- 
rated gout, was content to relegate this form of arthritis to the rheu- 
matisms. Hay garth, who suffered from, it, wrote the first classical 
description, and the Irish surgeons, Smith, Colles, and Adams, dis- 
tinguished it from surgical affections of the joints and gave it a sepa- 
rate place. 

Etiology. — The disease distinguishes itself by peculiar alterations 
of the joints, by an affection of all parts of the joint, and also by 
gradual implication of all the joints. Hence the propriety of the 
synonym of Hueter — polypanarthritis. Arthritis deformans is a dis- 
ease of age rather than maturity, though it may occur earlier in peo- 
ple in whom age is precipitated, as by alcoholism, atheroma, etc. 
Women are the greatest sufferers, and the poorer class, with many 
exceptions, is oftener affected. The disease sets in in two ways. 
First, and more commonly, it attacks the smaller joints, with a spe- 
cal predilection for the joints about the hand, the metacarpo-phalan- 
geal joints ; next, it affects the largest points, the joints of the verte- 
brae and the hip joint. 

In the great majority of cases it commences in the smaller joints j 
but, whether it commences in the smaller or in the larger joints, the 
natural tendency of the disease is to extend symmetrically until it 
involves them all. Various theories have been propounded to account 
for its origin. 1. The mechanical theory is that the alterations about 
the joints are due to trophic changes, because of mechanical pressure 
at the escape of the nerves from the intervertebral foramina. In 
this explanation it is implied that the bones of the vertebrae suffer 
first, which is by no means the case, even as a rule. 2. The chemi- 
cal theory, that there circulates some poison in the blood which 
expends itself upon the joints after the manner of rickets and lues. 
3. The neurotic theory, which implies some affection of the spinal cord, 
whereby the bones and joints suffer trophic change. Support is lent 
to this view from the well-known alterations in the bones and joints 
which occur in certain cases of locomotor ataxia. Charcot, Bene- 
dikt, and Remak favor this view. But the changes which occur in 
locomotor ataxia are more especially absorptive changes affecting 
particularly certain joints, the hip and the knee, and then in only a 
very small minority of cases. The evidence in favor of the neurotic 
theory of the disease is based mainly upon the fact that the disease 
occurs about the period of degenerative change and that it is distri- 






ARTHRITIS DEFORMANS. 625 

buted over the body symmetrically. The real cause remains as yet 
unknown. 

Symptoms. — Arthritis deformans declares itself for the most part 
insidiously. Cases have been reported in which, after depressing 
mental emotion, more especially prolonged sorrow or grief, dejection 
from financial strain, domestic inf elicit}", etc., arthritis deformans 
has developed in the course of a few weeks, but for the most part the 
disease sets in very gradually. There is noticed, first, a want of 
deftness and dexterity of the movements of the joints, remarked 
more especially in artisans and mechanics, fine lace and needle work- 
ers, piano players, etc. The fingers do not respond ; the fine, edu- 
cated movements, which have become more or less automatic, lag 
behind. There is stiffness, more especially noticed in the morning 
upon rising from bed, to pass away with exercise of the body ; later 
it becomes more marked and more permanent. Soon — that is, in the 
course of months rather than weeks — characteristic deformity shows 
itself, in that the metacarpophalangeal joints become swollen, ten- 
der, stiff. Partial luxation occurs later from the changes in the 
bones. The fingers are extended and flexed upon the hand, and 
come to lie over each other, to assume an imbricated arrangement, 
pointing usually toward the ulna, more exceptionally toward the 
radius. The position of the hand is now quite peculiar : it assumes 
something of the position of a bird's claw when first lifted from the 
perch. As the deformity advances more or less complete dislocation 
of the joints ensues. Other joints of the fingers swell, rendering ex- 
tension even more pronounced, so that at times the hand has the ap- 
pearance of being turned over. Atrophy sets in in the muscles. The 
hand is crippled ; it is also wasted. All the while, however, as a 
rule, the thumb remains unaffected, and by its range and power 
makes up in great degree for the loss of movement of the hand, so 
that the patient is still able to perform many, even delicate, move- 
ments. 

Strange to say, when the foot becomes involved, which is the 
case often simultaneously, oftener subsequently to the hand, the 
big toe is the joint first affected. The metatarso-phalangeal joints 
become dislocated in the same way as in the hand. The big toe 
joint is swollen, tender, and stiff — a deformity noticed but little, be- 
cause the foot is limited by its dress, but noticed on account of the 
pain from pressure. The shoe pinches, bunions form, the disease 
then involves other toes, and the nature of the affection is unmistak- 
able. Thereupon it extends to involve the wrist, the elbow, the 
shoulder, and gradually, in the course of years, more distant articu- 
lations. Finally the joints of the ribs, the clavicle, the jaw may be 
affected, but the disease advances rather by exacerbation and abate- 
40 



626 



ARTHRITIS DEFORMANS. 



ment than continuously. There are periods of acute inflammation, 
short in duration, followed by long periods of arrest or quiescence, 
each exacerbation leaving, as a rule, some, perhaps almost impercep- 
tible, additional lesion. The individual finally becomes hopelessly 
crippled. He may no longer dress himself, feed himself ; the body 
takes the position of the chair in which it rests. For a time after 
the individual has lost the power of motion he may help himself with 
canes, with crutches, with wheeled chairs, to which he finally be- 









Fig. 263.— Arthritis deformans. Section of cartilage of head of femur, x 40. a, hyaline' car- 
tilage ; b, hyaline cartilage with exuberant cartilage cells ; c, c, abraded cartilage ; d, clefts in 
cartilage ; e, spots of softening ; /, cartilage calls ; g, new marrow spaces ; h, new, i, old bone tis- 
sue ; k, old marrow spaces ; Z, osteoclasts (Ziegler). 

comes locked, and must be lifted from the chair to the bed, and at 
last must even have assistance to be turned in bed. 

The characteristic feature of the disease is the deformity. Irreg- 
ular changes of all kinds occur in the bones and the joints. Bony 
outgrowths, exostoses, protrude about the joint to cause dislocations, 
to swell the heads of bones, to obliterate cavities. Exacerbations 
make new cavities. Striations occur from friction ; sometimes such 
stimulation as to harden the bone to produce eburnations. Harden- 



ARTHRITIS DEFORMANS. 627 

ing and softening go side by side, eburnations and porosities, until 
at last the natural outlines of the bone are almost wholly destroyed. 

The cartilages suffer in the same way, now in certain places, now 
in others. The capsules, the tendons, finally the muscles which 
move the joints, become atrophied from disuse, so that in extreme 
cases the individual presents a characteristic appearance : the body 
is more or less emaciated, the joints are locked. Atrophic condi- 
tions occur also in the skin, and sclerodermatous patches, more par- 
ticularly surfaces of glossy skin, are not uncommon. All the while 
the sensorium is unaffected, the digestive system may remain unim- 
paired, the respiratory apparatus unattacked, the heart's action un- 
affected. For the most part, however, patients become, on account 
of their sufferings, irritable ; there is a tendency to hypochondri- 
asis ; there is constipation ; there is more or less impairment of 
the appetite and digestion, yet appetite and digestion continue to 
suffice for the reduced wants (motions) of the body. 

Diagnosis. — The disease is distinguished from acute rheuma- 
tism by the fact that it attacks the aged, and more especially the 
female sex ; that it remains fixed in the joints which it attacks, and 
produces permanent deformities ; that it is unattended with sweating, 
with fever, except in the acute complications, and with cardiac dis- 
ease. It is distinguished from chronic rheumatism by the affection 
of so many joints, chronic rheumatism being confined to one or a 
few ; by the attack of the smaller joints; by the peculiar deformity it 
produces in the smaller joints; by its universality. Distinction from 
gout, which it most closely simulates, has been described under gout. 

The prognosis quoad vitam is good ; most patients die of old age. 
Hay garth wrote his description of his own case at eighty. The prog- 
nosis quoad valetudinem is bad, in that in the great majority of 
cases the disease is permanent. It may be controlled, but not cured. 

Treatment must be general rather than local : warm baths, 
travel, sojourn in the South in winter, in the North in summer — 
i.e., ability to pick the climate in which the individual suffers least, 
as in the pine regions (Georgia, the Carolinas), on islands (Nassau), 
in the mountains, Virginia, Maryland rather than Colorado, or some- 
where in the varied climate of California. Locally the progress of 
the disease may be stayed by gentle friction, massage. Flying 
blisters in the more chronic cases are often of value. Electricity, 
the galvanic current more especially, is of occasional service. As to 
drugs, the most good is accomplished by arsenic. Small doses are 
to be given over a long time, that the action of the remedy may be 
sustained. Iodine has long had a reputation, more, really, than it 
deserves. It was first used by Lasegue, Trousseau's assistant, in 
the form of the tincture, ten drops three times a day, but is best 



628 RACHITIS. 

administered in the form of iodide of potassium or sodium with milk, 
in small doses long continued. Salol, the salicylates, salipyrin, 
have over the acute exacerbations the quickest control. Phenacetin 
may suffice to control pain. 

RACHITIS. 

Rachitis; rickets. — A disease of childhood, seven months to seven 
years, characterized by disturbance of digestion, bronchial catarrh, 
with characteristic changes in the skull, chest, and bones of the ex- 
tremities. 

History. — Glisson, a distinguished anatomist and physician of 
the seventeenth century in England, called this disease rachitis partly 
because of the popular name rickets for a disease marked by deform- 
ity of bone, and partly in deference to the Greek word rachis 
(paxiS), the spine, because of the distortions produced in the dorsal 
chest. The disease had long been known by the people and had at- 
tracted the attention of physicians, more especially of the counties of 
Devon and Somerset, in England. A prominent English physician, 
Whistler, described it as a disease of English children, and Conti- 
nental writers took it up as an English disease, though the changes 
characteristic of it had been recognized in bones almost from time 
immemorial, and are perpetuated in one notable statue, that of the 
famous ^Esop. 

Etiology. — It is difficult to assign rickets to its proper place in 
nosology. On account of the prominence of the bone deformities, 
especially in the neighborhood of the joints, the disease is generally 
discussed along with the rheumatisms. Because of the general dis- 
turbances which precede and accompany it, it is sometimes given a 
place by the side of tuberculosis and lues. The tendency in our day 
is to put it among the chronic infections of the blood by the side of 
tuberculosis and syphilis. 

Inasmuch as most of the main deformities of the disease can be 
accounted for by the softening of the bones, it was early supposed 
that rickets resulted from an insufficiency or a reabsorption of the 
lime salts. Chossat and Milne-Edwards withheld the lime salts from 
young animals and observed marked deformities in the build of the 
bones; but Friedleben, who repeated all these experiments, observed 
that while these deformities do occur, they are evidence rather of 
malnutrition and are not the characteristic deformities »of rickets. 
Guerin advocated the theory of malnutrition, and he, too, proved it 
by withdrawing young animals, puppies, from their mothers and 
feeding them with meats. Here too, however, the changes which 
occurred are to be ascribed, according to Tripier, to malnutrition and 
not to rickets. Wegleben declares that if phosphorus in small quan- 



RACHITIS. 629 

tities be administered to animals from whose diet the lime phosphates 
are withheld, changes occur exactly like those of rickets. 

Bone Changes. — These changes affect chiefly the ends of the 
bones. They grow larger to such degree as to overlap the joints as if 
by condyles. This development gives the appearance of the double 
joint which the disease is sometimes called. The enlargement is 
most observed where bone unites with cartilage, and is seen in most 
distinctive form at the junction of the ribs with their cartilages. 
Thus a line of nodules may be traced downward and outward from 
the first through the successive ribs to constitute what is known as 
"the rosary," or the beads of the ribs. Elsasser (1843) contri- 
buted an important fact to our knowledge of rickets in the observa- 
tion that the bones of the skull, especially the occipital bones, be- 
come softened in places. The condition is recognized by palpation 
of the head with the whole hand, with alternate pressure of the 
fingers, whereby spots of softening, the so-called craniotabes, are 
recognized, especially about the lambdoidal suture. Rickets shows 
characteristic deformities in the shape of the skull. The fontanelles 
close late, sometimes not until the end of the second or third years. 
The head fails, therefore, to assume its natural ovoid shape. It is 
flat on top, the frontal eminences protrude, the eyes seem sunken. 
It is claimed that the precocity of rickety children is due to the easier 
expansion, of the skull. Fagge says this fact, if it be a fact, is more 
readily explained by the confinement to the house of these children, 
their closer association with adults, and, we might add, more con- 
stant resort to books. The skeleton of rickety children is always 
short, hence the stature is diminished. Most dwarfs are victims 
of rickets. Of all the specimens examined by Ritterhein, but one 
came up to the normal standard. The bones of the face are also ar- 
rested in development. The face seems a mere appendage to the 
enlarged head. The jaw is narrow. Dentition is late ; the teeth, 
stunted, imperfectly covered by enamel, decay early. On account 
of the softening and elasticity of the bones of the ribs the anteropos- 
terior diameter of the chest is increased. The sides are flattened, 
the sternum protrudes to constitute what is known as ' ' the pigeon 
breast." The great glands, the liver and spleen, sink or are pushed 
below the level of the ribs to give undue prominence to the abdomen. 
The pelvis is deformed so that its conjugate diameter is shortened ; 
or other deformity ensues from pressure, as in support of the child 
upon the arm of the nurse, or even from long-continued decubitus. 
The bones of the arm yield outward, as do also the bones of the legs, 
to such a degree as to constitute what is known as bowlegs. Most 
of the aggravated cases of bowlegs in children are due to rickets. 
Rickety bones also are apt to break, especially with a vitreous or 



630 



RACHITIS. 



green stick fracture. Serious changes take place also in other organs 
of the body. 

Symptoms. — Rickets announces itself for the most part by symp- 
toms which may antedate the deformities of bone by weeks or 
months, to such degree often that the early recognition of the disease 
may prevent or limit subsequent changes. Thus disturbances of di- 
gestion, anorexia, diarrhoea, constipation, or disturbances of the 
respiratory tract, catarrhal affections and cough, may precede 
more distinctive symptoms for several weeks or months. The symp- 
toms may simulate the advent of tuberculosis, basilar meningitis, 
and all the more from the fact that the ages affected are about the 
same. It is soon noticed that the rickety child is restless at night, 





Fig. 264.— Deformities of rickets. 1, thigh of adult with rachitic deformity of diaphysis ; 2, 
thigh of adult with rachitic deformity of lower epiphysis. 

kicks off the covers, tosses about the bed uneasily, in marked contrast 
with its former quiet state. 

A symptom of more value is sweating, which occurs without 
provocation, which is not to be accounted for by the heat of the 
weather or by bedcovers. The sweating is all the more readily 
recognized because it attacks more especially the head and neck — - 
exposed parts of the body. It is observed also that rickety children 
are sensitive to pressure and to manipulation. They do not relish 
being fondled, dandled on the knee, or tossed. It is plain to see that 
any rough manipulation gives pain. The observance of any of these 
conditions — restlessness at night, sweating of the head, sensitiveness 



RACHITIS. 631 

— should excite the suspicion of rickets, which may be confirmed or 
refuted by examination of the bones. Rickets often announces itself 
so insidiously as to be preceded by no observable change, so that 
the disease becomes manifest only with the deformity of bone. 

On the other hand, the existence of the disease in even ad- 
vanced or rapidly advancing, and still unsuspected form, is made 
manifest at times by a violent spasm, more especially a larynyo- 
spasm. Spasm of the larynx belongs in nine-tenths of cases to 
rickets. The spasm occurs suddenly, in the day or night, as the child 
awakens from sleep, as it is moved, lifted, as it is carried, as the light 
is admitted to the room, as it is fed, on the approach of the spoon, as 
it is being examined, in some contact with the throat. Suddenly the 
glottis closes, and is held closed so that no air whatever enters the 
chest. The spasm may extend from the glottis to involve the mus- 
cles of the neck and jaws, or, indeed, of the whole body to present the 
appearance of tetanus. Such spasm is well to be distinguished from 
the spasmodic closure of the larynx in laryngismus stridulus, or false 
croup, where air may still enter with a long-drawn, stridulous, or 
crowing sound like that of true croup. In the croup case the closure 
is partial; in spasm, complete. False croup yields to a hot bath, to 
bromides, or to an emetic — remedies which cannot even be brought 
to bear in the treatment of spasm of the larynx in rickets. 

The diagnosis is easy if the existence of the disease be suspected, 
but is confirmed only by the presence of the characteristic changes 
in the bones. 

Prognosis. — Rickets is a disease which, undisturbed, runs a long 
course. It terminates spontaneously usually about the end of the 
second, sometimes not until the sixth or seventh year, but may be 
cut short, as a rule, in a few months by proper treatment. It has in 
itself no mortality. Fatalities are from complications — spasm of the 
larynx, true croup, bronchitis, pneumonia, etc. 

Treatment. — While it may not -be said that malnutrition is the 
essence of rickets, it is certainly true that in most cases errors of diet 
can be discovered. Sometimes the child is weaned too soon, some- 
times it is nursed too long, more frequently it is fed prematurely 
upon starchy food or meats, eggs, etc. That these dietary errors are 
insufficient to cause the disease is proven by the fact that many chil- 
dren of the poor, under the grossest errors of diet, escape it. Rickets 
is almost unknown in high altitudes and in the polar regions, places 
where children are fed in the coarsest way. It is, however, true 
that the error of diet acts as an excitant to the cause of the disease, 
whatever it may be, and that correction of this error plays an impor- 
tant role in treatment. 

Where the child may not be nursed by its mother, a wet-nurse 



632 RACHITIS. 

should be obtained ; but where this is not possible, as it is not pos- 
sible in the rule, a child should be fed with cow's milk properly di- 
luted, or, if older, the diet must be regulated with a proper selec- 
tion of meats, vegetables, and fruits, especially oranges, lemons, 
and grapes, later apples and cherries. Green things are essential 
in the treatment of rickets. Erroneous postures must be relieved. 
Nurses are to be enjoined to change the decubitus from side to side, 
and not to permit too long repose upon the back of the head. Mat- 
tresses and pillows should be soft. So, also, injunction should be 
entered as to the mode of carrying children, that the bones of the 
pelvis be not too much compressed. Rickety children are to be 
restrained in efforts at early walking, or traction with the hands, 
that bone deformities be limited or prevented. After the bones be- 
come hard in the further course of the disease, these methods are of 
no avail. Resort must be had in extreme cases to exsections, more 
especially wedge-shaped exsection of bones, in the correction of ex- 
treme deformity. Cod-liver oil holds a place between a food and a 
drug. It is administered best pure in tea- to tablespoon dose after 
each meal. It certainly contributes largely to the relief of rickets. 
Iron may be a valuable remedy, as also arsenic, in selected cases ; 
but the agent upon which most reliance is placed, which acts nearly 
as a specific in the treatment of rickets, is phosphorus. To Kasso- 
witz is due the debt of this discovery. Lime phosphates and other 
phosphates had been administered for years in the hope of relieving 
rickets, but without avail. Phosphorus is of value only when it may 
make its own compounds or select its own basis in the body. It is 
best given, therefore, pure, in the form of an emulsion with almond 
oil, olive oil, or preferably cod-liver oil. 

I£ Phosphorus gr. £. 

Olei morrhuoe 5 ii. 

% 
M. Fiat emulsio. S. Teaspoonf ul three times a day after meals. 

Laryngo-spasm is most efficaciously treated by cold affusions. 
There is no possibility of the administration of an anaesthetic, as the 
child cannot breathe until the spasm is over. Cases liable to laryn- 
go-spasm should be treated with the consideration of cases of tetanus 
and hydrophobia, with reference to outside irritation. The dress 
should be open. The child should rest upon an oil-cloth or rubber 
cover, that the garments may be quickly removed, and the face, 
chest, and neck douched with cold water. Muth says he recovers his 
worst cases by inflating the lungs through a catheter — a process that 
might be better accomplished in our day by intubation. Such inter- 
vention is, however, really superfluous. Nearly all cases recover 
with time under the general treatment of the disease. 



OBESITY. 033 

Osteomalacia is a disease of adult bones, characterized by ab- 
sorption of already deposited lime salts with corresponding soften- 
ing and deformity. It occurs especially in fertile women in preg- 
nancy, hence at the age of twenty to fifty, and is announced by pain 
in the bones, early fatigue, nervousness, muscular tremor, and 
twitching. Treatment is the avoiding of pregnancy, securing the 
most favorable hygiene, and administering lime salts, phosphorus, 
and cod-liver oil. 

OBESITY. 

Obesity (polysarcia, corpulence) is an abnormal increase of fat. 
The condition may be acute or chronic, but usually develops slowly. 
The amount of fat which may be consistent with health varies in 
different individuals, and in the same individual at different periods 
of life. People gain and lose weight, which is largely a matter of 
the amount of fat, within certain but indefinite limits, without inter- 
ference with comfort or health. The increase becomes pathological 
when it interferes with any of the natural processes. Obesity may 
be hereditary or acquired. The condition certainly runs in families. 
It is also more marked in certain races and places. It may be 
acquired by excess in nutrition and defects in exercise. Of foods, 
starch, sugar, and alcohol especially contribute to the formation of 
fat. A sedentary life, indolent habits, prolonged sleep, have the 
same result by diminishing consumption. The accumulation of fat 
is physiological after the meridian of life, especially at the period 
of the grand climacteric in women. ''Fair, fat, and forty " is a 
proverb. Most of the monstrous cases have been females. Benzen- 
berg's four-year-old girl weighed one hundred and thirty-seven 
pounds, Kisch's ten- year-old girl one hundred and sixty-two pounds, 
and Regnelle's eleven-year-old girl weighed four hundred and fifty 
pounds. The bulging face, big body, and waddling gait of these 
unfortunates always excite amusement, sometimes ridicule. 

Obesity shows itself in two fot*ms, the plethoric and anaemic 
(Kisch). The plethoric form is more common in men. It is distin- 
guished by fulness of vessels with stagnant circulation, redness of 
the face, distended pulse, hyperemia of the liver and lungs, haemor- 
rhoids, increase of the haemoglobin and of the number of red blood 
corpuscles. The ancemic form occurs especially in women and 
shows itself in opposite conditions — in pallor of the surface and of 
the visible mucosae, in weakness, languor, neurasthenia, palpitation, 
dyspnoea, oedema. The pulse is quick and feeble. The blood shows 
diminution of haemoglobin and reduction in the number of blood 
corpuscles. Transition forms occurs in both sexes. 

The accumulation of fat shows itself first by an increase at the 
sites of normal deposit, as in the subcutaneous tissue (panniculus 



634 OBESITY. 

adiposus). The natural contours of the body are increased. There 
is visible fulness in the cheeks ; under the jaw, which may present 
the aspect of a double chin ; in the breasts, on the abdomen, at the 
buttocks, etc. The breasts may assume monstrous dimensions, and 
the abdomen become pendulous upon the thighs. Fat accumulates 
also in regions where it is normally absent, as between the muscle 
fibres, under the endocardium, in the glands, etc. 

Of the internal organs the heart suffers most, and in two ways : 
by simple accumulation of fat under the pericardium and between 
the muscle fibres, and by degeneration of the fibres themselves. The 
subserous accumulation may be so great as to form a distinct en- 
velope — lipoma cordis capsulare ( Vircho w) . Under this condition the 
action of the heart becomes enfeebled. The impulse may be barely 
perceptible to the touch or ear. The pulse is correspondingly weak, 
and is often retarded (bradycardia). In fatty degeneration the 
changes are more grave. Fatty degeneration occurs much more fre- 
quently independent of obesity, and rather in connection with the op- 
posite state, with emaciation, and is the consequence of the action of 
toxines from infectious processes, malaria, typhoid fever, pyaemia, 
Bright's disease, cachexia, cancer, or of exhaustion by haemorrhage, 
diarrhoea, and is the evidence of chronic myocarditis. Fatty degene- 
ration occurs more especially in acute polysarcia and results from 
nutritive change. 

The lungs are likewise impeded in their action. The excursions 
of the chest are limited. Hyperemia supervenes. Attacks of bron- 
chitis are common. Asthma is wont to occur, more especially in con- 
nection with enfeebled action of the heart, and severe, even fatal, 
dyspnoea may result from stasis or oedema of the lungs. 

The increase in size of the liver is detected by percussion and palpa- 
tion. This increase is not attended with tenderness — a point of value 
in differential diagnosis from organic disease. Gall stones are of not 
infrequent occurrence in these cases, and they sometimes, though 
rarely, develop icterus. The stasis in the liver leads to hyperaemia in 
the radicles of the portal vein, and thus develops catarrh of the stom- 
ach with dyspepsia and constipation. The kidneys are embedded in 
a mass of fat and often show signs of stasis in oliguria, albuminuria, 
and oedema of the extremities. Glycosuria is also frequent, and 
diabetes mellitus develops in more than half the cases. These 
altered metabolic and nutritive changes which lead to obesity predis- 
pose also to the development of arterio-sclerosis, with disturbances in 
the circulation and liability to haemorrhage. The obese are gene- 
rally sluggish and dull ; they suffer with a feeling of fulness in 
the head, with vertigo, tinnitus aurium, muscae volitantes, and sensa- 
tions of formication. 



OBESITY. 635 

The sexual functions are likewise interfered with. Amenorrhcea 
is common. There is leucorrhcea from catarrh ; chronic metritis is 
not infrequent. Displacements are common, and sterility is rather 
the rule. The genital organs are atrophied. 

The treatment, which is wholly a matter of exercise and diet, de- 
mands often great self-denial and always much patience. Exercise 
is best taken on horseback. Children may substitute it with a bi- 
cycle ; adults with pedestrian excursions, especially with mountain 
climbing. Oertel justly lays much stress on withdrawal or limitation 
of water. On the other hand, Tarnier, Karell got good results on an 
exclusive milk diet, and the quickest results are obtained at Marien- 
bad, Austria, with regulation of exercise, hot baths, and massage, 
and free libation of the alkaline mineral waters. 

The importance of regulation of food was shown in the Banting 
method — a dietary on which Mr. Banting reduced himself in one year 
fr<fm two hundred and two to one hundred and fifty-six pounds. 
Improvements in this method were suggested by Ebstein and Oertel, 
whose formulae, according to Burney Yeo in Hare's " System of 
Practical Therapeutics/'' are published below. 

Ebstein recommends the use of fat because it satisfies with less 
food — a fact which seems to have been recognized even by Hippo- 
crates. 

The Ebstein dietary is as follows : Breakfast (6 a.m. in summer, 
7:30 a.m. in winter) : White bread well toasted (rather less than two 
ounces) and well covered with butter : tea, without milk or sugar, 
eight or nine ounces. Dinner (2 p.m.) : Soup made with beef mar- 
row; fat meat with fat sauce, four to five ounces : a moderate quan- 
tity of certain vegetables, asparagus, spinach, cabbage, peas, beans ; 
two or three glasses of light white wine ; after the meal, a large cup 
of tea without milk or sugar. Supper (7:30 P.M.) : An egg ; a little 
roast meat with fat ; about an ounce of bread, well covered with 
butter ; a large cup of tea without milk or sugar. 

Oertel's formula differs in allowing more albumen and starch 
and less fat, with a view especially of strengthening the muscle of 
the heart. This dietary is as follows : Morning : One cup of coffee 
or tea with a little milk, altogether about six ounces ; bread, about 
three ounces. Xoon : Three to four ounces of soup ; seven to eight 
ounces of roast or boiled beef, veal, game, or not too fat poultry ; 
salad or a light vegetable; a little fish {cooked without fat, if de- 
sired) ; one ounce of bread or farinaceous pudding (never more than 
three ounces); three to six ounces of fruit, fresh preferred, for des- 
sert. It is desirable at this meal to avoid taking fluids, but in hot 
weather, or in the absence of fruit, six to eight ounces of light wine 
may be taken. Afternoon : The same amount of coffee or tea as in 



636 OBESITY. 

the morning, with, at most, six ounces of water; an ounce of bread 
as an exceptional indulgence. Evening : One or two soft-boiled 
eggs, an ounce of bread, perhaps a small slice of cheese ; salad and 
fruit ; six to eight ounces of wine with four or five ounces of water. 
Weir Mitchell advises massage, with skimmed-milk diet, to effect 
a safe and quick reduction in weight. The milk is to be given' in 
just such quantity as to permit a loss of half a pound a day. 



DISEASES OF THE 

GENITOURINARY SYSTEM. 



CHAPTEE IX. 

DISEASES OF THE KIDNEY. 

Definite knowledge of the diseases of the kidney during life 
dates from the discovery by Richard Bright (1827) that certain forms 
of dropsy are distinguished as due to kidney disease by the pre- 
sence of albumin in the urine. Dropsy, which had hitherto been 
considered a disease, was now degraded to a mere symptom of dis- 
ease, and the ability to distinguish one cause of the dropsy was thus 
established. Bright followed his cases to the post-mortem room. 
He observed that certain diseased conditions of the kidney were 
found in cases characterized by albuminuria during life. It seems 
strange that so much knowledge should flow from a test so simple. 
It had been occasionally remarked before, especially by Cotugno, 
that the urine of dropsical patients sometimes contained albumin, 
but no one before Bright had ever appreciated the full value or the 
clinical significance of this observation. Bright' s paper was enti- 
tled " Cases Illustrative of some of the Appearances on the Exami- 
nation of Diseases terminating in Dropsical Effusion," and the cases 
themselves are described under the title ' ' Diseased Kidney in 
Dropsy." 

Bright believed that the disease originated in the stomach or 
skin, and attributed it mainly to cold and bad living, including 
abuse of alcohol. Two years later Christison, of Edinburgh, pub- 
lished a paper entitled "Observations on the Variety of Dropsy 
which depends on Diseased Kidney," and two years later again 
Gregory issued a treatise on " Diseased States of the Kidneys con- 
nected during Life with Albuminous Urine." In 1831 Osborn, of 
Dublin, wrote a work on " The Nature and Treatment of Dropsies 
accompanied by Coagulative Urine and Suppressed Perspiration." 
So that the relation between dropsy, albuminuria,' and disease of the 



638 DISEASES OF THE KIDNEY. 

kidney received ready recognition. Bayer, of Paris (1840), pub- 
lished an exhaustive treatise on diseases of the kidneys, which he 
treated under the title " Albuminous Nephritis." Frerichs (1851) 
distinguished three stages : hy persemia, fatty degeneration with exu- 
dation, and hyperplasia with atrophy. By this time already all 
forms of kidney disease were grouped under the general title Bright's 
disease. Rokitansky (1842) was the first to describe a special form of 
kidney disease, known as amyloid degeneration, which does not really 
belong to the category of Bright's disease. The study of the rela- 
tion between the heart and the kidney, first developed by Bright, 
but especially elaborated by Traube (1865), constituted a luminous 
epoch in the history of the disease. 

These affections of the kidney distinguish themselves by their 
distribution. The process in B right's disease is diffuse, not localized 
or circumscribed, and various forms admit of more or less distinct 
recognition. These forms may be found associated, or one form may 
pass into another. There are combined forms and transition stages, 
but as a rule there may be distinguished in life a form which pre- 
dominates and gives character to the disease in symptomatology, 
prognosis, and termination. Such forms only as may be recognized 
in life merit practical consideration. 

While the pathology of kidney disease has undergone much 
change since the time of Bright, and every pathologist multiplies di- 
visions or establishes new forms, there may be set apart as distin- 
guishable in life three special forms. 

Of these forms two affect the structure proper, the parenchyma 
of the kidney, understanding by this term the epithelium which 
lines the tubules and covers the glomeruli. Parenchymatous nephri- 
tis is separable, again, into acute and chronic forms, for the most 
part of easy distinction during life by symptoms which stand apart. 
In the third form the inflammation affects chiefly the connective tis- 
sue, which undergoes hyperplasia with subsequent shrinkage, to pro- 
duce the condition known here as elsewhere as cirrhosis. A fourth 
variety, which, as stated, does not belong to B right's disease, of later 
recognition, affects first and chiefly the blood vessels, whose tissue 
it alters and destroys to constitute what is known as the amyloid 
change. 

A disease which unfits the kidney for its function reveals itself 
(1) in the secretion of the kidney, the urine ; (2) in the effect of reten- 
tion of toxic elements (uraemia) ; (3) in the disturbance of the circu- 
lation (dropsy). In the separation of kidney disease a case should 
be approached from the standpoint of the information furnished by 
the urine, the nervous system, and the dropsy. Distinctions may be 
drawn by differences more or less pronounced in these respects. 



ALBUMINURIA. 639 

ALBUMINURIA. 

The urine is especially distinguished by the presence of albumin 
(albuminuria), which is recognized by the simple test of coagulation 
under heat to the boiling point and under nitric acid. These two 
tests correct each other of any fallacy pertaining to one alone. Phos- 
phates precipitated by heat with the escape of carbonic acid, which 
helps to hold them in solution, are dissolved by the addition of nitric 
acid, and urates precipitated by nitric acid are dissolved under heat. 
When the urine is alkaline the nitric acid should be added in amount 
equal to one-fifth of the volume of urine. These simple tests suffice 
for all clinical purposes. Mistakes in diagnosis result, not from fail- 
ure to resort to more delicate, but from neglect of use of these simple,, 
tests. 

The quantity of the albumin is roughly estimated by volume, by 
the size and density of the coagulum. Urine rendered cloudy or 
opaque by the presence of blood or pus, detritus, etc. , must be first 
filtered. If it still remains cloudy, usually on account of abundance 
of bacteria, it will be rendered clear by shaking in a test tube with 
magnesia usta. Albumin from sources outside of the kidney struc- 
ture, as from the pelvis of the kidneys, ureters, bladder, etc. , belongs 
to the blood, pus, or other exudation which makes the urine opaque. 
Outside diseases are also recognized by other signs of these affections. 
Albumin from the kidney always indicates affection of the epithelial 
cells ; it is, therefore, always pathological. There is transitory and 
intermittent, but there is no physiological, albuminuria. Any inter- 
ruption to the circulation of blood through the glomeruli, any 
interference with the nutrition of the epithelial cells, permits the pas- 
sage of albumin. Kidneys rapidly exsected under these circum- 
stances show a layer of albumin, under the microscope, surrounding 
the glomeruli. They also show alteration, cloudiness, multiplication 
of nuclei, etc. , in the epithelial cells. , 

Albumin in quantity up to one-tenth of one per cent is said to be 
slight. Such a quantity may be transitory and may indicate no or- 
ganic disease. One-half of one per cent is a medium grade : one to 
two per cent a high grade of albuminuria. The presence of albumin 
alone does not necessarily indicate disease of the kidney, as albumin- 
uria occurs in all the infections, in blood anomalies, anaemia, etc.. 
icterus, certain nervous diseases (paralysis, epilepsy), certain poison- 
ings (arsenic, opium, chloroform, etc.). It is the constant presence 
of albumin in association with some of the other signs (casts, urae- 
mia, dropsy) that establishes the diagnosis. 

True albuminuria distinguishes itself also by its quantity, which 
in false albuminuria is small. True is further separated from false 



640 DROPSY. 

— i. e. , outside albuminuria (from the bladder, urethra, etc.) — mainly 
by the microscope. 

CASTS. 

Of even more importance than albuminuria is the presence in the 
urine of casts, or moulds, of the urinary tubules. These casts are 
made up of coagulated albumin, and may contain in addition epithe- 
lial cells, blood corpuscles, fat globules, detritus, etc. They some- 
times undergo subsequent degeneration into waxy matter. Casts 
which consist wholly of coagulated albumin are known as hyaline 
casts. They are clear and colorless, and, though they have linear 
contours, are often overlooked. Hyaline casts are rendered more 
distinctly visible for the beginner by the addition of a drop of a 
dilute watery solution of methyl violet. In this way, also, true casts or 
true cylinders are distinguished from the " cylindroid" bodies, mere 
mucous casts, very long masses of mucus, extending through several 
fields, sometimes split like a fork or teased into threads, with lines of 
granules along the surface, which are made visible or more visible 
by dilute acetic acid. Casts which contain, or are composed of, blood 
corpuscles, red or white, epithelium, fat globules, granules, etc., are 
known as blood, epithelial, fatty, granular, and waxy casts. 

Epithelial casts occur as actual linings of the urinary tubules 
desquamated in continuo, or as epithelial deposits upon a hyaline 
basis. The epithelium may be intact or degenerated into fatty, 
granular, or waxy matter. Epithelial casts indicate actual disease 
of the kidney structure. They are found especially in acute nephri- 
tis or in the acute complications of chronic nephritis. 

Granular casts are recognized by the dark color of the granules, 
which are particles of albumin or fat. They are broader and shorter 
than hyaline casts, and uniformly granulated. They represent de- 
generations of epithelium, and occur in the course of all kinds of 
nephritis. 

Waxy casts are also broad and short. They are homogeneous, 
faintly lustrous, j^ellowish, with straight or often irregular con- 
tours. They represent a stage of degeneration later than the gran- 
ular, and occur in the more chronic forms of nephritis. The pre- 
sence of a number of waxy casts in the sediment makes the 
prognosis very grave. 

DROPSY. 

Dropsy is due to retention of water on account of defective elimi- 
nation. It shows itself as oedema of the loose connective tissue, and 
is usually observed first in the morning in the lower eyelids; later, at 
the ankles, in the legs. Still later it invades the body, including the 
serous sacs, to produce anasarca. It is sometimes limited to the 



URAEMIA. 641 

mucous membranes, and may take life in the form of oedema of the 
glottis, lungs, or bronchi. The fluid of dropsy is distinguished by its 
abundance of salt and minimum amount of albumin. 



UREMIA. 

Uraemia results from the accumulation in the blood of urea and 
the various salts which should be excreted by the urine. It usually 
corresponds to the reduction in the quantity of urine, but stands in 
necessary relation only to the solid matters voided. Uraemia may 
occur when large quantities of urine are voided, as in renal cirrhosis, 
in which the bulk of the urine is simple water. It is observed not in- 
frequently after the disappearance of dropsy, with the absorption of 
solid matters accumulated in the dropsical fluid. Uraemia shows 
itself in its effects upon the nervous system, in headache, hebe- 
tude, somnolence or insomnia, and anxiety. It is a frequent 
cause of obstinate dyspepsia with corresponding degradation of 
health and strength. Uraemia distinguishes itself especially by ir- 
ritative signs, twitching s of the muscles of the face and extremities, 
spasmodic contractions, convulsions rather than comatose states. 
Epileptiform convulsions and comatose states in adult life, in the ab- 
sence of a history of epilepsy or syphilis, should excite the suspicion 
of uraemia. These attacks distinguish themselves from epilepsy by 
their frequent repetition in a short time, as in the course of a sin- 
gle day, and long interval, often of several months. Epilepsy 
may show the same interval, but not the same immediate recur- 
rence. Sudden blindness, amaurosis of central origin, results from 
the action of the poison on the occipital cortex. It usually disap- 
pears in the course of twenty-four to forty-eight hours. Vomiting 
and diarrhoea, direct effects of irritation of the nervous system, 
often discharge urea vicariously and recover the patient from con- 
ditions of danger. More rarely the urea is discharged by the skin. 
The poison sometimes attacks the respiratory centre, when the pa- 
tient is seized with attacks of dyspnoea simulating asthma, to con- 
stitute the so-called renal asthma, which is recognized by its 
connection with the other signs of uraemia or of nephritis. 

During attacks of uraemia the pulse is usually retarded, but is 
always full and hard. This condition of the pulse depends upon 
hypertrophy of the left ventricle, which always occurs in the 
course of chronic nephritis, and is due to the increased work thrown 
upon the heart to overcome the obstruction in the kidneys. The 
hypertrophy of the heart is recognized, besides, first by the in- 
creased tension of the pulse ; second, by the increased area of im- 
pact ; third, increased cardiac dulness ; and fourth, accentuation of 
41 



642 HYPEREMIA. 

the aortic valve sound — all in the absence of evidence of valvular 
disease. 

The quantity of /urea is reached roughly, but sufficiently accurately 
for all practical purposes, by estimate of the whole amount of solid mat- 
ter. The healthy adult voids in twenty-four hours 1,500 cubic cen- 
timetres, containing 25 to 40 grammes — i.e., 2-3.5 per cent — urea. 
Recent investigations show that in health but 84 to 90 per cent, average 
87 per cent, of the nitrogenous matter is urea, while in disease 82 to 86 
per cent, average 84 per cent, is urea. The rest is made up of other 
compounds of nitrogen, uric acid, xanthin, kreatinin, chromogen," 
ammonia. The amount of urea does not always correspond with 
that of the other solids. Thus in high fever, notwithstanding the 
increase of nitrogenous matters, there is a relative decrease of urea. 
Ammonia is increased in fever, and in high degree in diabetes, while 
the other extractives are diminished in amount. But knowledge of 
these points is not yet sufficiently precise to be utilized in diagnosis. 
We do not yet know which of these bodies produce uraemia. The 
amount of urea itself is very variable. It varies in different layers 
of urine in the same bladder (Edelfsen), and estimates are still made 
from the solids. Clinical experience has shown that the multiplica- 
tion of the two last figures of the specific gravity by 2 furnishes 
the quantity of solids for 1,000 grammes, whence the whole quantity 
is easily computed. Thus in health the specific gravity of a sample 
from the whole quantity, twenty-four hours, 1,500 cubic centimetres, 
is 1020, and 20x2 = 40 for 1,000 cubic centimetres, in all 60 grammes 
solids. Again, the specific gravity from a whole quantity, 1,875 
cubic centimetres, is 1012, and 12x2=24 for 1,000 cubic centimetres, 
for 875 is - 8 iWf- = 21, which added to 24 = in all 45 grammes solids. 
The estimate is of especial value in the inception of chronic nephritis 
and for diagnostic purpose in renal cirrhosis. 

HYPEREMIA. 

Hyperemia of the kidney (stasis) occurs in consequence of inter- 
ference with the general circulation, as in diseases of the lungs and 
heart. Stasis of short duration interferes with the action of the 
epithelial cells ; permits the escape of albumin, which may form 
a transparent, colorless exudation in the urinary tubules, to appear 
in the urine as the so-called hyaline casts. In the long-continued 
stasis which occurs in the course of chronic heart failures, the kid- 
ney becomes hard, the color fades from the cortical substance, to 
constitute the condition known as cyanotic induration. Infarction 
is attended with the accumulation of blood in the affected domain 
and haemorrhage into the capsule and urinary tubules. Destruction 



ACUTE PARENCHYMATOUS NEPHRITIS. 043 

of the kidney substance ensues, with the formation of extensive 

cicatrices. 

ANAEMIA. 

Ansemia of the kidney occurs in the course of general anaemia, 
reduces the size of the kidney, and diminishes the quantity of urine. 
In chronic states it is best observed in the course of senile atrophy 
and arterio-sclerosis, when the urinary tubules in the affected regions 
are found collapsed, empty, and filled with atrophied epithelial cells. 
The arteries are bent and tortuous, in places obliterated; the con- 
nective tissue hyperplastic: the substance of the kidney is often 
permeated with cysts. 

ACUTE PARENCHYMATOUS NEPHRITIS. 

Acute inflammation of the kidney was recognized before the days 
of Bright. It was not known, however, that the disease was a dif- 
fuse process. It was simply assumed that disease of the kidney ex- 
isted, on account of the change in the condition of the urine. Wells 
had actually called attention to the fact that the urine after scarlet 
fever might contain albumin, even in the absence of blood. Bright 
himself did not appreciate the relation between scarlet fever and 
disease of the kidney, and probably had no occasion to observe the 
changes of acute nephritis. It is interesting to note that Hamilton 
as early as 1833 declared that he had found the scarlet-fever kidney 
in a case without dropsy. All nephritis is caused by the passage 
through the kidney of toxic matter. It was assumed that a ready 
explanation of the frequency of Bright's disease would be found in 
the passage through the kidneys of micro-organisms on their way 
out of the body. It was, however, soon observed that micro-organ- 
isms do not escape from the kidney unless the kidney be diseased, 
and are even then to be discovered with difficulty. The abandon- 
ment of this view, that micro-organisms produced Bright's disease, 
seemed to disturb the dependence of these diseases upon infectious 
processes. With the discovery later of toxines and toxalbumins in 
the urine the relation of the infections was re-established. It was 
recognized that kidney disease could be produced by the injection of 
chemical irritants. A typical example of chemical irritant derived 
from life is offered in cantharidin, which may produce a typical acute 
nephritis. So this condition has been seen to occur after an extensive 
vesication, or more especially after the internal administration of the 
tincture of cantharides. Acute nephritis may occur in the course of 
any infectious process. Scarlet fever heads the list. Scarlet fever is 
the cause of more than half the cases of acute nephritis. The kidney 
complication occurs more especially in certain epidemics and is ab- 
sent in others. Thus of one hundred and eightY cases in 1853-54 



644 ACUTE PARENCHYMATOUS NEPHRITIS. 

treated by Bartels, twenty- two were followed by nephritis; and of 
eighty-four cases in 1863, thirteen showed the same complication, 
fatal, strange to say, in every case. Bartels declares that in other 
epidemics he had met scarcely a single instance in a hundred cases. 

Nephritis in these cases was formerly attributed to early exposure 
to cold. It was observed, however, that the accident occurred with 
equal frequency in cases long confined to the house and to bed. 
Nephritis was evidently not due to affection of the skin or suppres- 
sion of its secretions, as it is almost never seen after small-pox or 
extensive burns — conditions attended with the most marked destruc- 
tive lesions of the skin. The complication sets in, not in the course 
of, but as a sequel to, scarlatina proper. Nephritis develops some- 
where between the second and fifth weeks, in the average at the end 
of three weeks, after the disappearance of the eruption. It is, there- 
fore^ a post-scarlatinal process. Though it appears at this late 
period, it begins earlier and assumes proportions to make itself 
manifest by this time. It is needless to state that nephritis gravely 
complicates a case of scarlatina. 

After scarlet fever, diphtheria, among the infections, takes the 
second place in the production of this disease. The remaining in- 
fections — measles, rotheln, small-pox, pneumonia, etc. — only rarely 
show this complication; typhoid fever, for instance, not once in a 
hundred times. The diseases cited account for more than half the 
cases. Most of the rest are attributed to "taking cold." A certain 
contingent of cases is caused by pregnancy. These two factors act 
by liberating chemical poisons whose exact nature is unknown. 
Acute parenchymatous nephritis is, therefore, always a secondary 
process. 

Symptoms. — After scarlet fever and in the course of pregnancy 
the disease sets in suddenly, as a rule ; after taking cold the onset is 
more insidious. The attack may begin with a series of chills and 
light rise of temperature. There is noticed an increased frequency 
of micturition. The urine is reduced in quantity to one-half to 
one-quarter of the normal amount. The secretion is sometimes en- 
tirely suppressed. With the diminution in quantity there is cor- 
responding increase in specific gravity to 1025-1030. Where the 
quantity is not markedly diminished the specific gravity may not be 
materially lessened. The color may be darker from admixture of 
blood, and will show variations from a light tinge to almost black, 
corresponding to the amount of blood. Tested by heat or nitric acid, 
it shows albumin in quantity varying from a fraction of one to two 
per cent. Tube casts, epithelial and blood casts, are usually pre- 
sent. Dropsy occurs as a rule. It is usually first seen about the 
eyelids, which are puffed ; the face is swollen later. The face has 






ACUTE PARENCHYMATOUS NEPHRITIS. 



645 



a bloated, pallid, unwholesome look. Dropsy appears later in the 
subcutaneous tissue everywhere, and, in the course of the disease, in 
the serous cavities. It may take life by suffocation, from oedema of 
the glottis, or more especially from oedema of the lungs. 

Nervous symptoms are also prominent. Individual cases are 
ushered in with headache, severe neuralgic pain, vertigo, nausea, 
and vomiting. Occasionally the first intimation of the existence of 
the disease is a convulsion. The nephritis of pregnancy is wont to 
announce itself by sudden blindness and convulsions. Sopor, stupor, 
and coma belong to this state. 

The diagnosis is easy, as a rule. The preceding infection, when 
it shall have existed, the time, the occurrence, the peculiar train of 
symptoms, the state of the urine, the dropsy, and the nervous phe- 
nomena, unmistakably stamp the disease. 




Fig. 265.— Casts of the urinary tubules in nephritis : A, blood casts; B, hyaline casts. 

The prognosis is always grave, though the future is mainly de- 
termined by the early recognition and speedy treatment. A case 
assumes gravity in correspondence with the diminution of urine. 
Anuria is an ominous sign. Yet children have recovered after total 
anuria of three weeks ; in these cases the poisonous elements have 
found escape through other emunctories — intestinal canal, the skin, 
lungs, etc. The presence of blood is not so grave as might appear. 
Hematuria is common in acute nephritis. Yet the prognosis re- 
mains grave in the presence of bloody urine. The amount of albu- 
min may have its weight in determining the future of a case. Dropsy 
is not so dangerous as nervous symptoms, especially convulsions. 
Comatose states are always grave. Patients may succumb in any 
paroxysm of convulsion or in any attack of coma. The immediate 
effect of treatment has its bearing upon the prognosis. 



646 ACUTE PARENCHYMATOUS NEPHRITIS. 

Treatment. — Any knowledge of the nature of the disease process 
will carry with it the dangers of diuresis. The routine administra- 
tion of digitalis or other diuretic is dangerous. The kidneys are 
already clogged, the blood vessels are ectatic, the tubules blocked 
with epithelial debris, blood casts, and detritus. The true treatment 
is to flush out the kidneys with frequent libations of water, preferably 
warm drinks. Mucilaginous drinks, toast water, have the advan- 
tage that they may be taken sweetened without aversion by a child. 
Adults take more kindly to acidulated drinks, lemonade, and soda 
waters. Milk is the best food, drink, and drug at any age. 

The scientific treatment of the dropsy consists in appeal to the 
skin whereby the kidneys are unloaded. Derivation of blood to the 
skin is best effected by the hot bath, which is, in the treatment of all 
forms of Bright's disease, almost a sine qua non. Patients, especially 
imacute nephritis, should be treated to the hot bath two or three times 
in the course of every twenty-four hours. The patient should be 
immersed in the bath, except the head, which should be enveloped 
in a towel wet with cold water. The temperature of the bath should 
be kept at 100° F., and there should be a supply of hot water to con- 
tinue this temperature during the bath, which may last from five to 
fifteen minutes. The patient is then rolled in blankets, put into bed 
previously warmed, and allowed to sweat for an hour or more. The 
process of sweating unloads the kidney. It happens not infrequently 
that the patient falls asleep after the bath, as the first restful sleep 
during the attack. A quantity of more normal, clear urine may 
pass immediately upon awakening. All clinical experience abun- 
dantly justifies this resort to the hot bath as the true treatment of 
acute nephritis. The bath, as stated, must be repeated again and 
again, and continued in the treatment of a case until all signs of the 
disease shall have disappeared. 

Where a bath is totally impracticable a substitute may be found in 
the hot pack. A child may be enveloped in blankets which are cov- 
ered in with a rubber cloth, and the body heated by hot bricks and 
hot-water bottles in the bed. The process is much more discomfort- 
ing than the hot bath and is much less efficacious. It has about the 
same relative virtue as the cold pack to the cold bath in the treat- 
ment of fever. The hot pack may be itself impracticable. Hot packs 
and hot baths alike at times affect the heart. In these cases resort 
may be had to the use of drugs, the most efficacious of which is pi- 
locarpine, which should be used with caution subcutaneously in doses 
of gr. T V~F-i- Sweating usually occurs rapidly, often within a few 
seconds, after the hypodermatic use of pilocarpine. It may also be 
profuse and may be sustained by repetition of the remedy. Pilo- 
carpine is a dangerous drug and should not be indiscriminately 



CHRONIC PARENCHYMATOUS NEPHRITIS. 647 

employed. The physician may have to choose this remedy as the 
lesser evil. Sometimes it acts admirably. 

Convulsive attacks must be cut short at once by chloroform or 
ether, and frequently repeated attacks may be prevented with the use 
of chloral in doses of ten to fifteen grains, more or less frequently re- 
peated. As a shield to the nervous system resort may be had also to 
the subcutaneous use of morphia. With chloral and morphia the 
brain may be protected until the poison of the disease is eliminated. 
As a rule the poison seems to inundate the nervous tissue in waves, 
so that vigilance and active treatment are demanded for several 
days or for a week or more. A light diet — milk — a warm tempera- 
ture, confinement to bed, later to the house, restraint of exercise and 
excitement, fulfil the remaining indications. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

This form constitutes the bulk of the cases of Bright's disease. It 
occurs less frequently alone ; it is often combined with other forms, 
especially with renal cirrhosis and amyloid degeneration. Yet dur- 
ing the greater part of its course it is independent, and becomes in 
its further progress associated with other forms. The view that 
Bright's disease presented itself as a single affection with three stages 
— acute and chronic nephritis and renal cirrhosis — proved so simple 
as to be seductive. It is, however, unfounded in fact. Chronic very 
rarely develops from the acute parenchymatous form. The acute 
nephritis which occurs in consequence of the infections, except scar- 
let fever, terminates life or terminates itself in resolution. It almost 
never becomes chronic. Occasionally the form that occurs in con- 
nection with scarlatina and pregnancy assumes a more chronic 
course. Rather more frequently the acute nephritis which is, for 
want of a better explanation, ascribed to cold becomes chronic. 
Those cases which result from suppurative processes, inveterate 
syphilis, and tuberculosis are more wont to become chronic because 
of persistence of the cause. All these causes combined constitute 
only the small minority of cases of chronic parenchymatous ne- 
phritis. 

The disease arises for the most part without discoverable cause, 
and develops itself so insidiously as to be recognized, as a rule, only 
after a duration of several months. Chronic nephritis develops in 
consequence of the existence of a concealed cause. The disease is 
for the most part as yet cryptogenetic. It is assumed that some 
chemical poison, a toxine in the process of slow elimination from the 
body through the kidneys, causes the disease. In connection with 
suppurative processes Fischer found the acid butyrate of soda, the 
escape of which through the kidneys might have caused the disease. 



648 



CHRONIC PARENCHYMATOUS NEPHRITIS. 



The question has interest, aside from the explanation of chronic kid- 
ney disease, as a demonstration of the existence of latent poisons. 

Symptoms. — Chronic parenchymatous nephritis distinguishes it- 
self, as a rule, by its insidious onset. The patient complains of no 
signs which distinctly refer to the kidney. Sometimes there is pain J 
more often dull, dragging sensations in the region of the kidneys, 
to be attributed sometimes to distention of the capsule (hyperemia), 
but rather to lumbago than disease of the kidney. The disease 
shows itself usually first in depression of spirits and degradation 
of energy. Life loses its zest ; avocation, before a pleasure, becomes 
a drag. Effort brings on early fatigue. There is loss of appetite, 




Fig. 266.— Retinitis albuminurica with irregularly scattered white patches (Magnus). 



listlessness, drowsiness or the opposite state, insomnia. Sleep 
fails to refresh. The color changes, the hue of health is lost to be 
substituted by pallor, which becomes an ashy-gray. There is loss 
of tv eight, which progresses gradually and indicates with the gene- 
ral failure of health what the people call a decline. But there is or 
need be no cough and no other sign of disease of the lungs. Patients 
consult the physician for repair of broken health and relief of broken 
spirits. Sometimes there may be noticed early puffiness about the 
face, bloating of the eyelids, swelling of the ankles. After the 
work of the day the shoes are tight. The swelling subsides in the 
night. 

The disease sets in less frequently with nervous signs. There is, 
with the hebetude, headache, neuralgic pains — trigeminal, sciatic, 



CHRONIC PARENCHYMATOUS NEPHRITIS. 



649 



much more frequently occipital and intercostal. There may be pal- 
pitation and shortness of breath to simulate the onset of tuberculosis 
or heart disease. The diagnosis is sometimes first established by the 
oculist, who discovers in a retinitis albuminurica an explanation of 
the disease. 

The urine is diminished in amount to two pints, to a pint, to a 
half-pint or less, in twenty-four hours. There is seldom that ex- 
treme oliguria, and never the absolute anuria, which is sometimes 
seen in acute nephritis. The occurrence of anuria would indicate 
a complication, more especially the supervention of acute nephritis. 
In accord with the reduction in quantity is an increase in specific 
gravity to 1025-1030-1040, weights which excite the suspicion of 
diabetes, which is readily excluded by observation of the diminu- 




Fig. 267.— Epithelium in urine of nephritis : A, desquamated cells, many in fatty degeneration; 
B, epithelium from pelvis of kidney ; C, epithelium from female (above) and male (below) urethra 
(Wesener). 

tion in quantity. The urine is also correspondingly turbid. On 
standing a heavy sediment falls to jbhe bottom of the vessel. Al- 
bumin is always present. Albumin distinguishes itself not only 
by its presence, but by its amount. It may exist in the urine in an 
amount which is not equalled in any other form of kidney disease. 
All the fluid seems to set solid on boiling or on addition of nitric 
acid. The albumin may amount to as much as five per cent. It 
usually ranges about one or two per cent. The sediment consists of 
epithelial detritus, fat bodies, white blood corpuscles, and tube casts. 
White corpuscles are present in large amount. Nearly all forms of 
tube casts may be observed in different cases — hyaline casts ; epi- 
thelial casts which show fatty change ; desquamated epithelial cells, 
also in a state of fatty degeneration ; granular casts, more strictly 
indicative of chronic nephritis ; and broad, tuaxy casts, which are 



650 



CHRONIC PARENCHYMATOUS NEPHRITIS. 



found exclusively in chronic nephritis and in advanced forms of the 
disease. They distinguish themselves by their size as well as by 
their color. They represent advanced changes in the epithelium of 
the larger and of the largest tubules. They contribute more than 
any other element in the urine to make the diagnosis and to estab- 
lish the prognosis. 

The dropsy distinguishes itself also by its amount. It is or be- 
comes universal. It varies of course in degree, but may be discov- 
ered somewhere in the body in nearly every case. In one hundred 




Fig. 268.— Chronic nephritis : epithelial and mixed casts (Peyer). 



consecutive cases Johnson found it absent only twice. It is noticed 
first, as a rule, about the face, but soon shows itself in the lower ex- 
tremities and accumulates in the subcutaneous connective tissue to 
constitute anasarca. It mounts up the legs, the skin of which it 
may distend to the utmost degree. The surface then becomes tense 
and shiny as if glazed. Finally rupture may occur with the escape 
of fluid in continuous quantity, and sometimes with subsequent ex- 
tensive sloughing and gangrene. The serous cavities are subse- 
quently invaded. Fluid accumulates in the peritoneum, in the 



CHRONIC PARENCHYMATOUS NEPHRITIS. 651 

pleura, and most dangerously in the pericardium. (Edema of the 
glottis is not quite so frequent as in the acute form of the disease ; 
but oedema of the lungs, especially in connection with subsequent 
heart failure, often terminates the disease with the life of the patient. 
(Edematous states of the mucous membrane of the intestinal canal 
are not infrequent. Obstinate vomiting and diarrhoea, sometimes 
with sloughing and the formation of ulcers, distinguish certain cases. 
Inflammations of the various serous membranes, pleuritis, peritoni- 
tis, pericarditis, inflammation of the lungs, pneumonia, as excited 
by the presence of toxic matters, constitute terminal links in the 
chain of disease process. 

The nervous symptoms in this form of kidney disease are com- 
paratively insignificant. They may assume prominence in an indi- 
vidual case. The disease, as stated, may be announced by headache, 
vertigo, the neuralgias, etc., or convulsions and comatose states may 
occur in the progress of the disease ; but these ursemic symptoms are 
infrequent. They are noticed also to occur less frequently in cases 
of most extensive dropsy. It is assumed that the dropsy is a kind 
of reservoir for the accumulation of toxic matters, which are thus 
held in solution away from the blood and nervous system. All kinds 
of nervous symptoms may occur in exceptional cases, marked even 
by dropsy, and ugly pictures are sometimes shown of convulsions in 
a body distended and distorted by dropsy. Any predominance of 
nervous symptoms would indicate a case complicated with acute 
nephritis or renal cirrhosis. 

The diagnosis rests upon the general failure of health and 
strength, upon the bad color, loss of appetite, progressive emaciation. 
The emaciation may be masked by dropsy, but is manifest in ex- 
treme degree with the subsidence of the dropsy. The diminution of 
the quantity of urine, the high specific gravity, the turbidity, exist- 
ence of albumin in quantity, presence of a heavy sediment of white 
blood corpuscles, tube casts, and detritus, the dropsy which distin- 
guishes itself by its range and amount, the few, scattered, and for 
the most part insignificant nervous symptoms, distinguish this form 
of Bright's disease. 

The prognosis is always grave, mainly for the reason that the 
disease is not recognized until damage is done. But chronic paren- 
chymatous nephritis is by no means of necessity fatal. Other things 
being equal, it may be said that the future is determined by the 
duration of the disease. A case which has lasted not over a year 
may recover. The character of the tube casts, more than any 
other single element in the urine, determines the prognosis. The 
presence of broad, waxy casts especially indicates an advanced stage 
of the disease. Dropsy is not dangerous. The largest accumula- 



652 CHRONIC PARENCHYMATOUS NEPHRITIS. 

tions may be speedily removed and reaccumulations may be held 
below the line of danger. Nervous symptoms are always grave in 
correspondence with their own gravity. Convulsions and coma are 
ominous signs. 

The treatment does not differ materially from that of the acute 
form of the disease. The true principle of therapy is the flushing of 
the kidney of its epithelial debris and exudation, and elimination of 
the toxic elements through the skin. The patient should drink freely 
of water, pure water, alkaline mineral waters. Milk is both food 
and drink, and cases have been cured by milk diet alone. Unfortu- 
nately in chronic nephritis life may not be sustained indefinitely on 
this diet. Buttermilk is an aid and substitute, as is also kumyss. 
The most scrupulous attention must be paid to the skin, which 
should be protected from every exposure. Patients with this form 
of BrigmVs disease should remain in doors in all bad weather. Blus- 
tering, raw winds should be shunned. Wet weather is dangerous. 
In any kind of acute exacerbation or advanced form of the disease 
the patient should stay in bed, where alone may be secured an 
equable, warm temperature. Underclothing must be warm and clean. 
The same dress may not be worn day and night. The diet should 
be simple, plain, and nutritious. It should consist mainly of vege- 
table food. Baths must be given as directed in the treatment of 
acute nephritis. They are especially indicated in the presence of 
nervous signs. There is not the same objection to the use of cardiac 
diuretics in chronic as in acute nephritis. To strengthen the force 
pump while the sluice gates are opened is to attack the disease in 
flank as well as in front. The most effective diuretic is digitalis, 
which may be given at first, in the form of the effusion, in teaspoon- 
ful, dessertspoonful, or tablespoonful dose. The infusion should be 
made fresh from the leaves, and the use of it should be discontinued 
so soon as the pulse under its full action becomes firm and hard. 
Too prolonged administration may tetanize the heart. After several 
days the remedy may be resumed in the same or less dose, or in 
another form, as the tincture five to fifteen drops. As the infusion 
does not keep long, a small quantity, six to eight ounces, should be 
prescribed at a time. The preparation is made much more efficacious 
in the treatment of kidney disease by the addition of ten to fifteen 
grains of the acetate of potash to each dose. Digitalis may be for 
various reasons contra-indicated. It may be substituted by stro- 
phantus, gtt. v.-xv., diluted, three times a day. For quicker action 
resort may be had to the natro-benzoate of caffeine in two- or three- 
grain powders every two or three hours. The powder, dry upon the 
tongue, is usually washed down with soda water. Still better is diu- 
retin in solution: 



RENAL CIRRHOSIS. 653 

R Diuretin. 3 i.- 3 ij. 

Aquae menthse piperitse % iv. 

M. S. Tablespoonful every two to four hours. 

For immediate results in cases complicated with cirrhosis no remedy 
equals nitroglycerin, which not only tones the heart, but has the 
additional advantage that it relaxes any spastic contraction of the 
arterioles, especially in the kidney, to permit an easier release of 
accumulated matter. Where the distention of the skin threatens to 
produce rupture with its associated dangers, this accident may be pre- 
vented by the introduction of fine silver canulae, South ey's tubes, or 
by puncture in several places, as on the dorsum of the foot or the 
most distended part of the leg. Great caution must be exercised 
with these punctures that the skin be washed clean with soap and 
water and rendered aseptic with the solution of sublimate 1 : 1000. 
The physician may not use the knife which the surgeon employs for 
other purposes. The most minute puncture suffices to permit the 
escape of a drop, which oozes down in a fine stream to discharge in 
the course of time surprising quantities of fluid. Dyspnoea, so great 
as to cause orthopnoea, may be relieved in this way in a single night. 
There must be dyspnoea or other great discomfort, or threatened 
rupture of the skin, to justify the procedure. Sometimes a dose or 
two of elaterin, or of calomel after the mode specified in heart dis- 
ease, may postpone the necessity of puncture. In subsequent treat- 
ment resort is usually had to the iodides, which are best given with 
milk. The tincture of iron gtt. xv.-xxx. in sweetened water, bitter 
tonics, tinctura rhei aromatica 3 ss.- 3 i., strychnia, as in the tincture 
of nux vomica gtt. x.-xx., may be demanded in an individual case. 
A change of residence to a warm, dry climate is worth all the drugs 
in the materia medica. 

RENAL CIRRHOSIS. 

Interstitial nephritis rarely occurs in the course of, or as a se- 
quence to, other forms of kidney disease. The transition of acute 
into chronic parenchymatous nephritis is more frequent than the 
occurrence of the cirrhotic kidney in consequence of parenchymatous 
inflammation. The processes may be combined, but they may not 
be said to originate the one from the other. There is certainly a re- 
lation between renal cirrhosis and gout. English and French writers 
describe the gouty kidney. This relation is rarely observed in our 
country, because of the infrequency of gout. 

Morbid Anatomy. — Though the obvious anatomical lesion is a 
hyperplasia of the connective tissue to such degree as to strangulate 
vessels, tubules, and epithelial cells, the disease does not begin in the 
connective but in all cases in the parenchymatous structure. Renal 



654 RENAL CIRRHOSIS. 

cirrhosis shows on section the small granular kidney with adherent 
capsule, atrophied cortex, retention cysts, and apoplexies in the sub- 
stance of the kidney. 

Etiology. — Renal cirrhosis arises for the most part from unknown 
cause. Luxurious habits, alcohol, heavy meals, more especially of 
meat, have been accused of causing this form of nephritis, but with- 
out proof. Renal cirrhosis occurs in all classes — among domestics, 
artisans, merchants, professional men. It occurs without regard 
to avocation. It is unknown in infancy and is rare in age. The 
majority of cases are discovered between adolescence and maturity. 
^ The great number of apparent cases in age are considered as scleroses 
of advanced life. The disease is four times as frequent in men as in 
women. 

Symptoms. — Renal cirrhosis is the most insidious of all forms of 
kidney disease. It may reveal its presence suddenly, as by a stroke 
of apoplexy, but even in these cases, as a rule, only after a long, 
more or less latent existence. During this latent stage there is the 
same general degradation of health and spirits noticed in the 
other forms of chronic nephritis. The color changes, the hue of 
health is substituted by pallor. Fatigue follows slight effort. Ner- 
vous signs predominate. Headache is frequent and obstinate. 
The condition may be first disclosed by an attack of asthma. Palpi- 
tation of the heart is a frequent precursor and attendant of the dis- 
ease. Certain cases consult the oculist for blindness or disturbance 
of vision. The first symptom to excite suspicion at times is haem- 
orrhage, frequent and severe — nose-bleed, or haemorrhage from the 
stomach or bowels. Not infrequently the physician is led up to the 
diagnosis by an examination of the urine, made in the absence of 
any other signs adequate to explain the condition. The urine is 
abundant. It is usually clear, limpid, with a greenish tinge. Pa- 
tients must pass water several times during the night; they are 
hence easily misled to believe that the kidneys are perfectly free from 
disease. The quantity may be doubled or trebled. Urine is dis- 
charged more frequently at night because it is secreted more abun- 
dantly at night. At times there is associate thirst, which, with the 
greater discharge of urine, may bring the patient to the physician 
with a suspicion of diabetes. The specific gravity is light, 1010 
and under. The urine is clear, deposits on standing but little sedi- 
ment, and shows but few isolated hyaline casts. So scant is the de- 
posit of sediment that the urine should stand in a conical glass over 
night to collect it, or, better, be precipitated in the centrifuge appa- 
ratus, which causes immediate or quick deposit by rapid rotation. 
Permanent preparations are kept by being bedded in glycerin-gelatin : 
gelatin one part, water six parts, glycerin nine parts, with a few 



RENAL CIRRHOSIS. 655 

drops of carbolic acid. Albumin may be entirely absent in the 
specimen examined, hence the necessity of collecting the urine of the 
twenty-four hours; a sample from the whole quantity will nearly 
always reveal albumin, but usually in very slight amount. It forms 
on boiling, or on the addition of acid, a slight cloud, which reveals 
itself best by contrast with the fluid in an unheated test tube. It is 
a good plan to boil simply the upper strata. When the tube is held 
against a dark background, the mantelpiece or coat sleeve, a very 
slight opacity is perceptible. The urea is correspondingly diminished. 
Dropsy is usually absent. It may show itself at some time or other 
during the course of the disease, and always accumulates at the close 
when the heart begins to flag in its force, but it is absent, as a rule, 
during the progress of the disease Yet the disease is sometimes 
announced by puffiness of the eyelids and oedema of the ankles, and 
in the last stages, for the reason stated, there may be anasarca or 
oedema of the lungs. As a. substitute for the absence of dropsy, and 
as a cause for its absence, there is enlargement of the heart. The 
left ventricle undergoes hypertrophy. Bright noticed this change, 
and attributed it to extra work thrown upon the heart by the occlu- 
sion in the kidneys, and to chemical change in the blood which irri- 
tates the heart. Thus symptoms on the part of the urine and symp- 
toms connected with dropsy are few and far between in renal 
cirrhosis. On the other hand, the nervous symptoms distinguish 
themselves by their prominence. Individual cases are announced, as 
stated, by attacks of apoplexy, which may result from simple uraemia 
or from actual break of a vessel in the brain. Apoplexy or coma in 
adolescence or maturity, without other obvious cause, should excite 
the suspicion of Bright's disease. The same thing may be said of 
epilepsy. Where this disease has not existed in the previous history 
attention should be at once directed to the kidney. Headache, neu- 
ralgia, vertigo, disturbances of vision, occur throughout the course of 
the disease. Asthmatic attacks are not infrequent. They occur in 
the night with the same dyspnoea and distress as in true asthma. 
Patients succumb to some expression of uraemia more frequently in 
this than in other forms of chronic nephritis. Explanation of the 
frequency of uraemia with free, copious urine is found in the fact that 
the urine, though free, contains but little solid matter. Uraemia 
results from the retention of toxic matter whose exact nature is 
unknown. Exemption from uraemia is due to the fact that the urea 
is eliminated through other avenues — the lungs, skin, the intestinal 
canal. Crystals of urea are sometimes, though very rarely, seen 
upon the face, to present the appearance of hoarfrost or a surface 
freshly lathered for shaving. The odor about the body is sometimes 
marked. 



656 RENAL CIRRHOSIS. 

The diagnosis of renal cirrhosis is not difficult. The voidance of 
excessive quantities of clear urine of light specific gravity, nearly 
free of albumin, detritus, and tube casts, stands in marked contrast 
to the reduced quantity of turbid, highly albuminous urine of paren- 
chymatous nephritis. The absence of dropsy is a striking feature 
Dropsy is absent, as stated, so long as the hypertrophied heart may 
force fluids through the kidney. The great frequency and severity 
of nervous symptoms speak also for renal cirrhosis. Hypertrophy 
of the heart may occur also in parenchymatous nephritis. It occurs 
always in renal cirrhosis. It is recognized by displacement of the 
apex to the left, increase in dulness to the left, accentuation of the 
aortic valve sound, heard best at the second interspace on the right, 
increase in the tension of the radial pulse. 

The differentiation of renal cirrhosis from renal arterio-sclerosis, 
always difficult, is sometimes impossible. Arterio-sclerosis is more 
distinctly a disease of age or of alcoholism. Patients are usually 
males who have suffered no previous disease of the kidney, who begin 
to show light ursemic signs, with slight dropsies (oedemas) which 
come and go. Attacks of palpitation point to hypertrophy of the 
heart, which is readily recognized. The urine shows albumin in 
traces or transitorily, sometimes also hyaline casts, but, instead of 
being increased, is, as a rule, decreased in quantity. The diagnosis 
really rests more upon the evidence of age or of arterio-sclerosis else- 
where, especially in the brain. 

The prognosis is always grave. The natural tendency of the dis- 
ease is to continued destruction of the kidney substance. The conse- 
quences of this evil are averted for a time by hypertrophy of the 
heart, so that the affection of the heart, as revealed especially by the 
state of the pulse, is a gauge of the gravity of the disease. Ursemic 
symptoms are always grave. Convulsions and coma are ominous 
signs. Attacks of asthma occur late in the history of the disease. 

The treatment differs in no respect from that of parenchymatous 
nephritis. There must be made the same appeal to the skin in 
substitution of the kidneys as before, and treatment must be continu- 
ally directed to sustain the heart and reduce the tension in the distant 
vessels. The hot bath is practised with the same precaution as be- 
fore. The temperature should be kept at 100° to 110°, and the 
patient should remain in the bath from five to fifteen minutes or 
more. Sweating is to be encouraged by blankets and hot teas. 
When the heart begins to flag it must be stimulated with digitalis, 
strophanthus, or caffeine. To relieve the resistance offered by tension 
of the arterioles no remedy is so good as nitroglycerin, which may be 
administered in doses of one to three drops every four to six hours. 
Administration of the remedy may^be continued in varying doses for 



AMYLOID DEGENERATION. 657 

several weeks. The diet should be simple, chiefly vegetable, largely 
fluid. Milk is the best animal food. It may be agreeably substi- 
tuted, especially in summer, by buttermilk, or at any time by 
kumyss. The skin must be protected by warm underclothing at all 
times, and by stay in the house in bad weather. During any exa- 
cerbation the patient should remain in bed, Other evils are coun- 
teracted after methods already discussed. 

AMYLOID DEGENERATION. 

The amyloid kidney is not one of the forms of Bright's disease. 
The process is diffuse and is part of a widespread degeneration. The 
condition is recognized, as a rule, only when it attacks the kidney, 
and may hence be best studied in this connection, especially in that 
it so frequently complicates or results from other forms of kidney 
disease, notoriously from chronic parenchymatous nephritis, which 
is itself a suppurative process. 

History. — Amyloid degeneration was first seen on the post-mor- 
tem table, as might have been anticipated, in the liver. 

Budd says of Laennec, who noticed everything, that he noticed 
also the " waxy " liver, which he, however, considered to be a va- 
riety of fatty liver. The first mention of the condition with a dis- 
tinct description was made by Antoine Portal in 1813, who says 
that he ' i found the liver excessively voluminous, reduced to a sub- 
stance like lard, both in color and consistence, in the body of an old 
woman who had various exostoses and ulcerations about the genital 
organs." Nothing but unimportant and isolated observations, as by 
Budd, Andral, Graves, were then made in the history of amyloid 
degeneration until 1842, when B,okitansky cleared up the field by 
showing that amyloid degeneration was a general process with local 
expressions in different organs, and that it stood in close genetic 
relations to certain cachexia?. Rokitansky was the first to describe 
amyloid degeneration of the kidney. Gairdner and Sanders' next 
(1851) demonstrated that the waxy condition of the liver and kidney 
also showed itself in the spleen, while Yirchow and Meckel almost 
at the same time (1853) had already discovered the iodine and sul- 
phuric-acid reaction which enables the pathologist to distinguish amy- 
loid matter in any organ at any time. It was this reaction which 
gave it its name. Starch is colored blue by free iodine. The color- 
ation of amyloid matter is not blue, but violet, deepening to mahog- 
any. Virchow called it matter like starch — i.e., amyloid. Fried- 
reich and Kekule (1860) demonstrated that it is neither starch nor 
fat, but a pure albuminous principle. 

After the nature of amyloid matter had been decided, the next 
point of interest was to determine whether it was a material circu- 
42 



658 AMYLOID DEGENERATION. 

lating in the blood and deposited in the tissues where it was found, 
or whether it was a result of disintegration or retrograde metamor- 
phosis of the tissue itself ; in other words, whether it was a mere 
infiltration or a true degeneration. 

What seemed to lend special support to the infiltration theory 
was the place of its first deposit. Virchow and Recklinghausen more 
especially emphasized the point that amyloid matter is first found in 
the walls of the blood vessels. Moreover, it was noticed that the 
most vascular organs — the spleen, the liver, and the kidneys, organs 
which stand in the most intimate relations with the blood — are the 
most frequently and extensively affected. But, it was maintained 
on the other hand, amyloid matter has never been found in the 
blood. Moreover, amyloid matter is not infrequently found in 
strictly circumscribed or isolated deposits, as a purely local change, 
and not as a local expression of a constitutional condition. Thus 
Billroth observed two cases in which individual lymph glands had 
taken on amyloid change ; Hirschfeld reported an amyloid degene- 
ration in a single mesenteric gland after a case of typhoid fever ; 
Kyber described cases of amyloid degeneration in inflammatory neo- 
plasms ; Oettinger, Samisch, and Leber, amyloid degeneration of 
the sclerotic, producing hypertrophic exuberations similar to those of 
trachoma ; Burow, a case of amyloid degeneration of a fibroid tumor 
of the larynx. Friedreich states that he got the amyloid reaction 
from the interior of old blood clots ; Juergens had the same results 
in thrombi of the endocardium ; Virchow from the intervertebral, 
tracheal, and symphyseal cartilages of old people ; lastly, Ziegler de- 
scribes amyloid tumors of the tongue and larynx that had developed 
in the immediate vicinity of old gummata which had run their 
course. 

Amyloid matter has four distinguishing characteristics — viz., a 
peculiar consistence (like dough or caoutchouc), a ivaxy lustre, a 
vitreous translucency, and a lack of color. But neither the ma- 
croscopic nor microscopic appearances enable us to pronounce upon 
it unmistakably. The true test of amyloid matter is its reaction 
with iodine and sulphuric acid. The surface to be tested must be 
first washed free of blood, else a mistake is very easy, and then 
painted over with a brush dipped in an aqueous solution of free 
iodine. In a few minutes the amyloid matter is colored violet or 
brownish-red like the color of mahogany. On the superaddition of 
sulphuric acid the mahogany color changes to blue. The iodide and 
chloride of zinc show the same reactions, as do also the iodide and 
chloride of lime ; and methylanilin distinguishes itself in this re- 
action by coloring the amyloid parts a beautiful red, while the un- 
affected parts assume a bluish or violet tint. 



AMYLOID DEGENERATION. 659 

Regarding age, sex, and social state, amyloid degeneration oc- 
curs at all ages, and even congenitally as the result of hereditary 
syphilis. Frerichs found among his sixty-eight cases three under 
the age of ten years and nineteen between the ages of ten and 
twenty ; and from Wagner's forty-eight cases it is seen to occur in 
five cases under ten and in five between ten and twenty. The male 
sex is two or three times more frequently affected — a singular fact, as 
Frerichs justly remarks, because the diseases which induce this de- 
generation by no means especially affect the male sex. Tuberculo- 
sis and syphilis have no regard for social caste, hence this affection 
is no respecter of persons. 

Amyloid degeneration follows, in the rule, some disease at- 
tended with protracted suppuration. Dickinson proposed an in- 
genious theory to account for it, based upon this fact, to wit : Pus is 
alkaline, and the long drain of pus dealkalizes the blood ; dealkalized 
fibrin is amyloid matter ; the scientific treatment of the condition, 
therefore, is the administration of the alkalies. Unfortunately for 
this beautiful theory, typical cases of amyloid degeneration may be 
unattended or unpreceded by suppuration. 

Tuberculosis is the most prolific cause of amyloid degeneration. 
Wagner gives the percentage of cases at 56.25, Weber at 40.55, Hoff- 
man at 67.5. Bone caries is followed by amyloid degeneration, 
according to Wagner, in 23 per cent of cases ; Weber, 38 per cent; 
Hoffman, but 7.5 per cent of cases. 

Symptoms. — The twine is increased in quantity, as a rule,, 
though never to the degree characteristic of renal cirrhosis. It is 
usually clear and shows light specific gravity, contains albumin 
in varying amount, sometimes scant, sometimes abundant, a feiu 
clear casts and white corpuscles. Dropsy is rare. What there 
is shoivs itself in the lower extremities rather than in the face, 
and is due not so much to the- kidney disease as to the general 
hydraemia of the cachexia. Many cases of amyloid kidney show 
no dropsy from beginning to end. Grainger Stewart saw general 
dropsy only six times in one hundred cases. With the oedema of 
the legs there is often ascites, due to obstruction in the portal vein 
from simultaneous affection of the liver. The process implicates also 
the mucous membrane of the alimentary canal. Vomiting and 
diarrhoea may be profuse and defiant of control. With much 
affection of the liver the stools are excessively offensive from lack 
of bile, and with much affection of the bowel they may show under 
the microscope, along with leucin, tyrosin, and fat, actual masses 
of amyloid matter, recognizable by the chemical test. 

"Symptoms on the part of the nervous system, so frequent in 
Bright's disease proper, are distinguished by their absence in amyloid 



660 TUBERCULOSIS. 

kidney. Bartels declares that he knew but one case of amyloid 
kidney to die of apoplexy. Hypertrophy of the heart does not occur. 

The diagnosis rests upon the fact that amyloid disease is a gene- 
ral process, and that affection of the kidneys coincides with affection 
of the spleen, liver, and often of the alimentary canal. Besides the 
history of the case, the connection with some suppurative process, 
and the kidney symptoms mentioned, affection of the liver and spleen, 
recognized by enlargement of these organs, and of the alimentary 
canal by profuse and obstinate discharges, make the diagnosis clear. 
The diagnosis has been established in doubtful cases by harpoonage 
of liver or spleen substance under antiseptic precaution — a procedure 
which is justifiable only in the most exceptional case. 

The prognosis in all cases of amyloid disease is bad. It is most 
favorable when dependent upon syphilis. Prevention by free evacu- 
ati6n of pus, and destruction or obliteration of pus-secreting surfaces, 
is the true treatment. Amputation, exsection, drainage, aspiration, 
are methods of prophylaxis and treatment of amyloid disease. The 
treatment of syphilis continued long after the subsidence of manifest 
signs, the thorough neutralization of chronic malarial poisoning, 
resort to change of climate in phthisis pulmonalis, prevent the devel- 
opment of amyloid disease. As to drugs, iodine alone is worthy of 
trial, because cases may depend upon concealed syphilis » 

R Sodii iodidi I i. 

Aquae menthge piperita § i. 

M. S. Ten drops in a wineglass of milk three times a day. 

Where iodine injures digestion, as it does sometimes, it should be 
discontinued until appeal may be made to the stomach with hydro- 
chloric acid and bitters, condurango, nux vomica, tinctura rhei aro- 
matica, etc. 

TUBERCULOSIS. 

Tuberculosis of the kidney is not common. It appears in the form 
of miliary tuberculosis, as part of the universal dissemination, some- 
times confined to a single branch of the renal artery, sometimes 
widely diffused, and as a chronic local deposit in the substance of the 
kidney or in its pelvis. As is the case elsewhere, tuberculosis forms 
granules and nodules, which undergo caseous degeneration, or break 
down to produce necroses, ulcerations, and extensive infiltrations. 
The disease is sometimes recognized by the evidence of tuberculosis 
elsewhere, more accurately by the discovery of the tubercle bacillus 
in the urine. But tubercle bacilli must not be confounded with 
smegma bacilli, which look just like them. In case of doubt the 
prepared specimen should be immersed a few minutes in absolute 
alcohol, which decolorizes the smegma bacilli but not the tubercle 
bacilli. 



FLOATING KIDNEY. 



661 



SYPHILIS. 

Syphilis of the kidney is even more rare. It shows itself in the 
hereditary form by intra-uterine arrest of development, and, after 
birth, with induration and shrinking. Now and then caseating 
gummata and cicatricial connective tissue are encountered in the 
kidneys of adults as the result of the acquired disease. 










J® 



fi 



■// 



FLOATING KIDNEY. 

Wandering kidney ; ren mobile. — The kidney is usually fixed in 
its position by the layer of fat in which it lies embedded, and is re- 
strained within light latitude of move- 
ment by the vessels of the hilus, which, 
with the connective tissue that binds 
them together, constitute something 
of a pedicle. An unusual laxity of 
this tissue and of the abdominal walls, 
more especially compression from 
above, as by corsets, belts, etc., dis- 
locates the kidney and allows it more 
or less wide range of movement. On 
account of the strain of hard work the 
condition is more common in the la- 
boring classes ; and, on account of the 
mode of dress, more frequent in wo- 
men than men. Sometimes both kid- 
neys are thus dislocated and rendered 
movable ; when but one, the right 
more frequently than the left. 

Symptoms. — In many cases the 
condition is entirely latent and is* dis- 
covered only upon autopsy. There are 
no symptoms upon the part of the kid- 
ney itself, so far as concerns its func- 
tion. The secretion remains the same. 
Attacks of dyspepsia, colic, icterus 
have been observed, and have been 
attributed to incarceration, which has, however, never been discov- 
ered upon the post-mortem table. They are better interpreted as 
neuralgias or as the result of a circumscribed peritonitis. More 
reliance may be placed upon pain, dragging sensations, or sen- 
sations of displacement, which are experienced as a rule. Some- 
times a tumor may be felt, by bimanual examination, in the region 
of the kidney. In thin persons, in whom the kidney may be often 






Fig. 269.— Topography of the kidney 
from behind, in relation to thoracic and 
abdominal viscera. Outlines of oesopha- 
gus, stomach, and large intestine in neavy 
dotted lines ; of liver and spleen in fine 
dotted lines ; of other organs in continu- 
ous lines. Crosses at seventh cervical, 
fourth and ninth dorsal, and first, third, 
and fifth lumbar vertebrae (Stedman). 
Compare with front view, page 583. 



662 FLOATING KIDNEY. 

grasped in the hand, it may be recognized by its shape. It is felt to 
be mobile; is movable, especially upward, but may be seldom carried 
beyond the median line. It is usually extremely sensitive. 

Diagnosis. — A floating kidney must be differentiated from a 
dislocated spleen or a small ovarian tumor. Aside from the fact 
that the left kidney is less movable, the spleen is larger, firmer, and 
much more superficial. The ovary differs in shape, moves down- 
ward rather than upward, may be recognized at times by a vaginal 
examination, or may be absolutely distinguished, in case of cystic 
growth, by aspiration. 

The prognosis is favorable so far as life is concerned. Any radi- 
cal correction of the displacement, except by surgical means, is diffi- 
cult. The enforced idleness which results from aggravation of the 
pain by work sometimes conduces to melancholy. 

Treatment. — Corsets, belts, must be abjured. Pads, compresses, 
and bandages may give mental, but rarely any real bodily, relief. 
Extirpation of the kidney, notwithstanding the fact that one is usu- 
ally large enough for all the wants of the body, is justifiable only 
in extreme cases, or really only in cases of disease of the kidneys. 
Harris reported sixteen nephrectomies, with ten recoveries. The 
kidneys were found diseased in three of the six fatal cases. Kronlein 
lost a case on the fourth day after nephrectomy from insufficiency 
of the remaining kidney. Attempt has also been made to transfix 
the kidney with a ligature passed into the abdominal walls through 
the kidney and out again, without permanent benefit. Hahn simpli- 
fied this operation by cutting down upon the kidney and stitching 
its capsule into the wound. Angerer cured seven of nine cases by 
fixation with catgut ligature. Such nephrorrhaphy is the proper pro- 
cedure. 



OHAPTEE X. 

DISEASES OF THE PELVIS OF THE KIDNEY, BLADDER, ETC. 
KIDNEY STONE — NEPHROLITHIASIS. 

Renal sand ; gravel ; calculus. — The old idea of a diathesis has 
been entirely abandoned, but stone in the pelvis of the kidney is still 
distinguished as nephrolithiasis. Nothing definite could possibly be 
known of the nature of stone in the kidneys until the discovery by 
Scheele (1776) of uric acid as a normal ingredient of urine. Scheele 
considered it the exclusive constituent of kidney stones. The dis- 
covery later of cystin, xanthin, oxalic acid, and the phosphates put 
the subject on solid ground. 

Nearly all the stones found in the urinary apparatus originate in 
the kidney. The proportion of original renal to vesical stones is 
100 : 1. There is great variation in size and number. A single stone 
may fill and form a cast of the pelvis of the kidney, or multiple 
stones — as many as one thousand have been counted — may distend 
the pelvis and ureter. Larger stones, as of the size of a goose egg, 
imply usury of the kidney substance. Gee described a case in which 
one thousand stones were found in the pelvis of the right kidney, 
one weighing 1,080 grammes, while the pelvis of the left kidney was 
taken up by a stone which weighed 100 grammes. The largest 
of these stones is the largest yet found. Kidney stones may be 
round, oval, angular, or irregular ; they vary also in surface, color, 
and consistence. 

Seven special forms have been described — stones of uric acid and 
urates, of oxalate of lime, of the phosphates, of the carbonate of 
lime, of cystin, xanthin, and indigo. Stones of the urates are hard, 
smooth as if varnished upon the surface, or granulated. They are 
usually small, varying in size from a poppy seed to a pea or bean. 
They are recognized by the murexide test. Scrape powder from 
the stone into a watch glass, or, better, a porcelain cover, add a 
drop of nitric acid, and heat to dryness. If now the brown spots 
of residue be touched with a drop of ammonia, there is developed in 
the presence of uric acid a brilliant carmine-red, the so-called 
murexide color. A drop of liquor potassae changes the carmine to a 



664 



KIDNEY STONE — NEPHROLITHIASIS. 



dark violet-blue. Oxalic-acid stones are distinguished by their 
extra hardness, as if varnished, dark color, and rough, warty sur- 
face ; they form the so-called mulberry stones. Heated to redness 
they turn white and effervesce with acids. Phosphatic stones are 
usually combinations of the phosphate of lime and the triple (am- 
monio-magnesia) phosphates. They are small and light, gray in 
color, and sandy or granular upon the surface. Soaked in potash 
lye and heated to redness they develop the odor of ammonia. Cys- 
tin, xanthin, and indigo stones are very rare. 

Cystinuria has now a new significance as a sign of infectious pro- 
* cess. Recent investigations (Stadthagen, Brieger) go to show that 




Fig. 270.— Crystals of oxalate of lime. In the middle the ordinary octahedra ; at the sides, 
disc, hour-glass, and dumb-bell shapes, x 275. (Eichhorst.) 



cystin is itself, or is the product of, a ptomaine in the intestinal 
canal, due to the action of certain micro-organisms. Cystin is found 
in the faeces and in the urine in connection with diamin. The acid 
urine decomposes the combination, the soluble diamin is discharged, 
and the insoluble cystin precipitated to possibly form a stone. Cys- 
tin is recognized by the fact that it occurs in small, colorless, hexago- 
nal tablets (see page 184), which are easily dissolved in ammonia to 
be precipitated again on evaporation of the ammonia. 

The etiology of kidney stone is obscure. Stones are found ten 
times more frequently in the male than in the female sex, and at 
both extremes of life rather than at maturity. Of 5,900 cases col- 



KIDNEY STONE— NEPHROLITHIASIS. 



665 



lected by Civiale forty-live per cent occurred in children. The abso- 
lutely greatest number of cases occur between the ages of two and 
twelve. Sedentary and luxurious habits, conditions connected with 
climate, food, and drink, have been accused, without proof, of pro- 
ducing kidney stones. Uric acid and urates are frequently found 
deposited as yellowish-red stripes in the pyramids of the kidneys of 
new-born children, to present the appearance erroneously called in- 
farction. It was believed that these deposits of the urates, as they 
occur only in consequence of tissue change, would be found only in 
children whose lungs had been expanded most abundantly, at two 
to twelve days after birth, and not, therefore, in the still-born. As 




Fig. 271 
horst) . 



-Mulberry-shaped red blood corpuscles in urinary sediment in haematuria (Eich- 



Hodann was able to demonstrate the condition in a decomposed kid- 
ney at the end of forty-five days, the finding assumed forensic im- 
portance. But as exceptional cases have been since reported, it may 
be said that the presence of this " infarction" constitutes not absolute 
but strong corroborative evidence of live birth. Concretions of uric 
acid may occur on account of excess of this substance in the blood 
or diminution of the salt which holds it in solution. Both conditions 
exist in certain cases. Individuals affected with gout may also suf- 
fer from kidney stones. Erasmus wrote to a friend: " I have gravel,, 
you have gout. We have married twins." 



666 KIDNEY STONE— NEPHROLITHIASIS. 

The Diphosphate of soda is the salt chiefly concerned in holding 
uric acid in solution. Diminution of this salt, the result of catar- 
rhal inflammation of the pelvis of the kidney, may lead to the pre- 
cipitation of uric acid. The phosphates fall in an alkaline urine, so 
that nephrolithiasis, so far as uric- acid and phosphatic stones are 
concerned — and they form the great bulk of cases — is always a local 
condition. 

Symptoms. — The presence of kidney sand may give rise to no 
symptoms, but even minute concretions may cause excruciating 
pain. Stones passed from the bladder are often much larger than 
stones in the kidney or ureter. 

Kidney stones usually reveal themselves by pain, which is ex- 
cessive in its severity. The pain is located in the region of the 
kidney, and radiates thence downward and inward toward the 
bladder. It is so excruciating as to require the use of an anaes- 
thetic, or large doses of opium, to secure relief. It is usually 
fitful, and irregular as the stone advances on release of spastic 
contraction, and often subsides suddenly with escape into the blad- 
der, some'times to leave the patient narcotized. The urine may 
appear perfectly natural, as it may issue only from the unaffected 
kidney, or it may be tinged tvith blood or contain pus from the 
affected kidney. Hcematuria and pyuria may thus alternate 
with perfectly normal urine. Accordingly, sediment may be 
scant or abundant, and examination of the deposit under the mi- 
croscope may disclose the presence and character of kidney stones. 
Sometimes, in consequence of complete occlusion, the kidney is con- 
verted into a retention cyst, to constitute a hydronephrosis. The 
kidney substance itself may be consumed and the capsule distended 
to such degree as to constitute a tumor in the abdomen. Pyelitis 
is a more frequent complication. Perinephritic abscesses may re- 
sult. Under these conditions sepsis may set in. 

The prognosis is always serious. The stone may rupture the 
ureter, whence peritonitis will develop. Abscesses with burrowing 
sinuses and fistulse may lead to slow marasmus and amyloid change. 
Nevertheless most cases recover. Patients pass the stones once for 
all ; more frequently a number of stones are passed in the course of 
a week or month, and the condition recurs once or twice in the 
course of a year. Sometimes the interval lasts several years. 

The treatment consists in the flushing of the kidney with abun- 
dance of drink, especially water, mineral waters, alkaline waters. 
The waters of Saratoga and Bethesda, any of the pure simple alka- 
line waters of our own country, may suffice. Better results are se- 
cured by Carlsbad water, natural, or preferably, with us, the artifi- 
cial salts. Lithia has long been used. Of late one of the coal-oil 



PYELITIS. 667 

products, piperazin, has been highly recommended. It is given 
in doses of gr. v.-xv. three to five times a day in a glass of soda or 
Selters water. It is said to have the power to dissolve uric- acid 
stones. 

The treatment of the attack is the relief of pain by the inhala- 
tion of chloroform or ether, by the subcutaneous injection of mor- 
phia gr. \, preferably with atropia gr. jfo, and by the administra- 
tion especially of chloral gr. xv.-xxx. to secure relaxation of spastic 
contraction and thus further the progress and final discharge of the 
stone or stones per vias naturales. Large flannels wrung out of 
boiling water and made to envelop the whole of the affected side 
assist in securing relaxation and relieving pain. 

PYELITIS. 

Pyelitis is an inflammation of the kidney produced by some irri- 
tating cause which develops in situ, or which escapes with the se- 
cretion of the kidney. The local cause is most frequently a stone — 
pyelitis calculosa — which may fret and irritate the pelvis and pro- 
duce hsemorrhage, suppuration, and ulceration. The cause may 
come from below, as from the bladder, cystitis: or from gonorrhoea, 
the use of unclean catheters, etc. It is commonly a mycosis, and is 
typically illustrated in the pyelitis which occurs in connection with 
tuberculosis. Pyogenic micro-organisms may find their way from 
the ureter to the kidney. More commonly the mycosis comes from 
above. Thus pyelitis occurs in the course of the graver infections 
— typhoid fever, small- pox, scarlet fever, diphtheria, cholera, etc. 
The micro-organisms themselves may not escape, but may do their 
damage by their products, the toxines and toxalbumins. A proof of 
this process is found in the p} T elitis which sometimes results from irri- 
tating drugs, cantharides, turpentine, copaiba, etc. Extension of dis- 
ease from the pelvis to the substance of the kidney produces pyelo- 
nephritis, which may terminate in the formation of abscesses and 
finally convert the kidney into a sac of pus, pyonephrosis, or extend 
to envelop the adjacent tissue as a peri- and para-nephritis, often with 
the formation of abscesses. A stone may increase in size to form a 
cast of the pelvis or of the whole kidney. Much more frequently it 
remains small and produces pyelitis. The process is almost always 
unilateral. Stone is more frequent in the left kidney. 

Symptoms. — Pyelitis is announced hy pain, more dull than acute, 
and more often manifest by sensations of tension and iveight. 
The pain usually radiates from the kidneys along the course of the 
ureters to the bladder. Pain is sometimes entirely absent. The best 
information is furnished by the urine, which contains pus or blood, 
or both, therefore albumin, and sometimes characteristic epithe- 



668 



PYELITIS. 



Hal cells. In a case of pure pyelitis the urine remains acid. Under 
retention from whatever cause, ammoniacal decomposition takes 
place with alkaline reaction. The cells are from the flattened cau- 




Fig. 272.— Epithelial cells from mucous membrane of renal pelvis, with prolongations and a 
shingled arrangement, from intact mucous membrane in man. x 275. 

date epithelium of the renal pelvis, and when present are pathogno- 
monic. Unfortunately they are absent in many cases, as they are 




Fig. 273.— Urinary sediment in acute pyelitis, containing epithelium, round cells, and red blood 
corpuscles, x 275. 

destroyed in ammoniacal urine. The presence of fever, with chills, 
diarrhoea, delirium, nervous signs, and the status typhosus, indi- 
cates pyelonephrosis or pyaemia. 



HYDRONEPHROSIS. 669 

The diagnosis rests upon the pain, if present ; the presence of 
albumin, blood, or pus in the urine ; more especially the characteris- 
tic epithelial cells : and, in connection with pyelonephrosis, the chills, 
fever, hebetude, and status typhosus. Pyonephrosis may form an 
abdominal tumor. 

The prognosis is always grave, but in the individual case de- 
pends upon the cause. It may disappear entirely after the discharge 
of a kidney stone or cure of a cystitis. The prognosis in the course 
of infection is always grave. It is more favorable after typhoid 
fever, in which disease it usually disappears with convalescence, than 
after pyemia, where it is often fatal. So long as the urine remains 
acid the outlook is good ; with ammoniacal decomposition the course 
of the disease is usually downward. 

Treatment consists in the removal of the cause, in the cure of 
gonorrhoea, the use of perfectly clean catheters, the removal of kid- 
ney stones. The administration of the salicylate of soda may pre- 
vent or postpone ammoniacal degeneration of the urine. The blad- 
der may be washed out with disinfecting solutions of creolin, 
one-quarter of one per cent. When there is no obstruction fluids 
must be administered freely to keep the kidneys flushed. Bad cases 
may require nephrotomy or nephrectomy. Guyon reported the cure 
of six cases of pyonephrosis by nephrotomy. The opening into the 
kidney must be wide and deep. 

HYDRONEPHROSIS. 

Cysts occur in the kidney in consequence of dilatation of the uri- 
nary tubules. The dilatation is most frequently observed in conse- 
quence of hyperplasia of the connective tissue, which causes com- 
pression and accumulation. Such cysts vary in size from a pea to a 
hen's egg, and are filled with colorless or yellowish fluid, more or 
less gelatinous, from which the 'true elements of the urine have been 
usually absorbed. A peculiar degeneration, wherein the whole sub- 
stance of the kidney is transformed into cysts which may assume 
magnitude by coalescence, is sometimes observed as a congenital 
malformation, to constitute the so-called cystic kidney. The same 
degeneration is sometimes observed in maturity and age, not infre- 
quently accompanied by a corresponding cystic degeneration of the 
liver. Occlusions in the pelvis of the kidney or the ureter, which 
block the escape of urine, lead to hydronephrosis. Such occlusions 
are most frequently formed by kidney stones, more rarely by cica- 
trices, strictures, compression of outside organs, tumors of the ute- 
rus and ovaries, enlargement of the prostate, etc. The kidney 
substance suffers usury under the pressure of accumulating fluid ; 
the capsule is distended to a sac which may contain from five to ten 



670 



CYSTITIS. 



pints of fluid. With the gradual disappearance of the kidney sub- 
stance the elements of the urine are absorbed and substituted by 
mucus which contains albumin, colloid matter, and sometimes 
blood, which imparts to the fluid a brown color. The condition is 
sometimes congenital, and in the experience of the author once 
formed, in labor, an obstacle which could be overcome only by punc- 
ture of the abdominal wall. The child was still-born. 

Treatment depends upon the cause, which must, as in the case of 
kidney stone, outside compression, etc., be discovered and removed. 
Surgical intervention may become a necessity. 





°4m 



Wh 





Fig. 274.— Stone causing hydronephrosis (Roosevelt). 



CYSTITIS. 

Cystitis (hvcttis, the bladder) ; inflammation of the bladder; 
catarrh of the bladder. — A disease distinguished by the presence of 
three symptoms, pain, frequency of micturition, and pyuria. Albu- 
min is present only in small quantity in correspondence with the 
amount of pus. 

Etiology. — Cystitis may develop by extension of disease from 
above or from below — that is, from the kidneys and ureters (pyelitis, 
calculus), and from the urethra (gonorrhoea, stricture, disease of the 
prostate gland). Cystitis may be also the local expression of tuber- 
culosis and cancer, in which processes the disease may extend to the 
bladder from contiguous structures (uterus, rectum, etc. ) or be car- 



CYSTITIS. 



671 






ried to it by the blood and lymph vessels. So, too, cystitis may 
develop in connection with an infection of the blood — pyaemia, sep- 
ticaemia — when the cause of the disease may be discoverable, or the 
affection may be cryptogenetic. Paralysis of the bladder, from dis- 
ease of the brain or spinal cord, tranma, tabes, etc., may produce 
cystitis from retention and decomposition of urine. A peculiar and 
rare form is attended with the formation of a false membrane, the 
pseudo-membranous cystitis. 

Gonorrhoea is the most frequent cause. Cystitis occurs in the 
later course of gonorrhoea, often when the discharge is reduced to a 
gleet or to a single drop in the morning. The gonorrhoea is some- 
times overlooked or unrecognized, as a posterior urethritis may de- 
velop without visible discharge. Posterior urethritis is detected by 
the presence of gonorrhoea! threads in the 
urine first passed in the morning, and by the 
presence of the gonococcus in the mucus. 

Symptoms. — The disease is distinguish- 
ed, as stated, by the association of three 
symptoms, pain, dysuria (frequency of 
micturition), and p iju via. Any one of these 
symptoms may occur in other affections ; 
all three only in cj'stitis. The pain varies 
in every degree of intensity, from light dis- 
tress to the most intolerable anguish. In 
acute cases it radiates from the bladder 
along the course of the urethra, involves 
the testicle and rectum, and is felt in inten- 
sity at the head of the penis. In these cases 
it is associated with intolerable tenesmus 
and dysuria. The desire to pass urine recurs every few minutes ; 
but a small quantity, a drachm or two, is voided under the most in- 
tense effort ; finally but a few drops of blood. The presence of pus 
is best observed in the urine which is passed first and last. With the 
development of cystitis the discharge of gonorrhoea usually ceases. 
The discharge should be examined repeatedly for the gonococcus of 
Neisser. 

Tuberculosis is, as a rule, primary in the bladder; that is, the dis- 
ease is derived from latent depots and not from the lungs. Tubercu- 
lar cystitis is especially distinguished by the presence in the urine of 
blood, which shows itself suddenly and apparently spontaneously, 
without much pain or dysuria. Tuberculous cystitis is often associ- 
ated with polyuria. The diagnosis is difficult because of the diffi- 
culty or impossibility of discovering the tubercle bacillus in the urine. 
In the absence of tuberculosis of the lungs, some expression of the 




Fig. 275.— Cyst ; tis with gan- 
grene and separation of the mu- 
cous membrane and part of the 
muscular coat (Gardner). 



672 ENURESIS. 

disease may be found elsewhere, as in the glands, joints, bones, epi- 
didymis, etc. 

Calculus produces intense pain, frequent haemorrhage, and tenes- 
mus, which are all increased by exercise of the body and relieved by 
rest. The stone may be felt by the sound. Stricture is discovered 
by the passage of a sound or bougie. In the membranous form 
flakes or masses of exudation containing epithelial cells, or consisting 
of actual exfoliations from the bladder itself, are voided with the 
urine or withdrawn by the catheter. 

Treatment. — Cystitis maybe prevented by the prompt and proper 
treatment of gonorrhoea, with the avoidance of strong injections at 
the start, by the use of clean catheters in retention, by the dilatation 
of strictures, withdrawal of stones, etc. Rest in bed is an essential 
factor. Hot drinks, tea, milk, mucilaginous drinks, are the best. 
The diet should be light and the bowels should be moved every day. 
Copious draughts of warm fluids flush the bladder. Pain may be 
relieved by hyoscyamine gr. i.— 3 i. ? gtt. iij.-v. every three or four 
hours, or atropia in the same solution and dose. Warm baths con- 
stitute the best remedy for dysuria. The injection of hot water into 
the rectum during the bath heightens the effect. More obstinate 
cases yield only to opium (gr. i. ) suppositories, or opium with extract 
of belladonna gr. ss., or rectal injection of tincture of opium gtt. x.- 
xv. with starch water. Dysuria which amounts to strangury re- 
quires a suprapubic subcutaneous injection of morphia. 

Gonorrhoeal cystitis is often cut short by the administration of 
copaiba or the oil of sandalwood in capsules containing gtt. v.-x. 
every two to four hours, or by the use of salicylate of soda: 

B Sodii salicylatis 3 ij. 

Glycerinse § i. 

Aquae menthse piperitse § iij. 

M. S. Tablespoonful every three hours. 

Chronic cystitis calls for irrigation of the bladder with solutions 
of boric acid three to five per cent, of sublimate 1 : 20,000 to 
1 : 10,000, creolin one-quarter of one per cent, nitrate of silver one 
per cent, etc. Astringent effects are best secured by the use of solu- 
tions of alumnol one per cent, sulphate of zinc one-tenth of one per 
cent, tannin one-tenth to one-half of one per cent. 

ENURESIS (INCONTINENCE OF URINE). 

Incontinence (in, negative, continere, to hold) of urine occurs es- 
pecially at the extremes of life, in age and childhood, and depends, 
aside from organic disease, upon overdistention from paresis of the 
detrusor with continuous discharge, or defective closure from paresis 
of the sphincter. 



SPERMATORRHOEA. 673 

Incontinence is frequent in women from dilatation of the urethra 
with relaxation of the sphincter in consequence of the strain and 
trauma of parturition. Involuntary dribbling or discharge occurs 
readily in such cases with coughing, sneezing, any exercise of the 
body. Masturbation may produce the same effect. Incontinence is 
frequent, too, in old men on account of atrophy or affection of the 
prostate gland (Peyer). Great care must be taken in all these cases 
not to mistake an overflowing for an empty bladder. The urine 
dribbles from a distended as well as from a paralyzed bladder. The 
most disastrous, even fatal, accidents have resulted from this mis- 
take. The use of a clean catheter will at once clear up any doubt. 

Enuresis (sv, in, ovpi]Gi?, passing water) is the involuntary, and 
usually unconscious, discharge of normal urine from a normal blad- 
der. Enuresis is a neurosis of the sphincter, and is for the most part 
a persistence of the infantile state, where the resistance of the sphinc- 
ter is very slight. So enuresis is most frequent at night, when the 
influence of the will is withdrawn by sleep and the innervation of the 
sphincter is defective. The condition shows itself especially between 
the ages of three and ten, sometimes not until puberty, and then at 
times in connection with onanism. 

Treatment. — Inspection occasionally reveals verrucosities or poly- 
poid excrescences at the orifice of the urethra in girls, the exsection 
or cauterization of which relieves the condition. Debilitated children 
must be built up with quinine, iron, cod-liver oil, and especially with 
exercise in the fresh air. Cold baths contribute to fortify the body 
in this regard. Atropia gr. i.- § i., gtt. iij. at bedtime, is the remedy 
of most value. It must be given with great caution to delicate chil- 
dren, and gradually increased to tolerance, not beyond dilatation of 
the pupil. The most effective treatment is the use of electricity, 
which is safely brought into indirect contact with the sphincter 
through the rectum. The current should be feeble, scarcely percep- 
tible, and may be gradually increased to tolerance with sessions of 
five to ten minutes every other day. Treatment usually requires a, 
period of four to five weeks. Exceptional cases are very obstinate. 

SPERMATORRHOEA. % 

Spermatorrhoea {(J-mspfxa, sperm, peoo, to flow), an abnormal dis- 
?harge of semen. An overflow which may occur once or twice a 
month is not disease. The condition becomes pathological when the 
3 is more frequent. In this regard individuals differ, and 
i is, in a manner, a law unto himself. The abnormity con- 
30 much in the frequency as the effect. The physiological 
is followed by a sense of relief; an excess, by exhaustion, 
latorrhcea is for the most part a misnomer. In many cases 
i3 



674 SPERMATORRHEA. 

the discharge is not semen, but secretion from the prostate and ac- 
cessory glands. Prostatorrhcea is often a more appropriate name. 
The secretion, with few exceptions, may be declared to be semen 
when the fluid contains spermatozoids (vide page 184, Fig. 127, 3). 
In the few exceptions these structures are absent (vide Impotence). 

The loss occurs chiefly with the discharge of urine and with the 
act of defecation. In the urine it is seen more especially at or just 
after the end of micturition. The patient may be unaware of its es- 
cape, and recognize it or suspect it only from the turbidity of the 
urine, or the physician may come upon it in the examination of the 
urine or its sediment. 

With the discharge of faeces it is always visible, as the seminal 
fluid is expressed by the mass of fseces itself. In more aggravated 
cases the patient is able to express the fluid, or comes to the physician 
with the statement that he feels its passage or presence, sees it at the 
orifice, and knows it to be semen by its greasy or " soapy " feel. 

Etiology. — Masturbation is the most frequent cause of sperma- 
torrhoea. Sexual excess also finally renders the nervous system 
irritable. Posterior urethritis, inflammation of the prostatic portion 
of the urethra, involving especially the caput gallinaginis, due chiefly 
to gonorrhoea, constitutes a constant irritation. An elongated pre- 
puce, a natural or acquired phimosis, which retains secretion; ab- 
normal states of the rectum and anus, constipation, ascarides, ecze- 
matous eruptions, haemorrhoids, are outside irritants which may 
much more exceptionally excite the genital centres. 

Symptoms. — Besides the presence of the discharge, the nature of 
which may be demonstrated by the microscope, a real spermatorrhoea 
Is attended with a sense of weakness, languor, and depression, with 
various paresthesias and vaso-motor disturbances, flashes of 
heat, vertigo, and headache. Most persons are affected with hypo- 
chondriasis and melancholia, conditions which are produced rather 
by degrading habits — onanism, sexual excesses, and perversion — 
which cause the spermatorrhoea, or are intensified by the perusal of 
popular literature regarding the disease. Dyspepsia, palpitation, 
and dyspnoea, dependent upon anaemic conditions of the blood, occur 
later in Khe course of the affection. 

Diagnosis. — True spermatorrhoea shows spermatozoids in the 
discharge. Prostatorrhcea furnishes a thin, milky fluid of character- 
istic spermatic odor, containing numerous lecithin granules and crys- 
tals of the phosphates (sperm crystals), which fall in abundance 
on the addition of a one-per-cent solution of ammonium phosphate. 
Prostatorrhcea furnishes no spermatozoids. 

Phosphaturia, a secretory neurosis, or a deposit from local cause, 
a condition without any real clinical significance, sometimes imparts 



IMPOTENCE. 675 

to the urine a turbidity or a milky color which is cleared up at once 
on the addition of a few drops of acetic acid. 

Treatment consists in regulation of the habits, abstention from 
masturbation and sexual excesses, relief of dyspepsia and gastric 
catarrh, the education of the mind to a better tone. Matrimony is 
the most effective remedy; as a rule it renders all others superfluous. 
Hydrotherapy — a cold bath every morning, especially a cold douche 
— invigorates the nerve centres. A dose of the bromide of potas- 
sium, gr. xx.^-xl. in a glass of water at bedtime, may subdue the 
excitability of the nerve centres and prevent nocturnal pollution. 
Posterior urethritis is best treated by injections of nitrate of silver, 
one to three per cent, with the catheter, after the manner already 
described. Electricity in both forms, faradization and galvaniza- 
tion, short sessions and feeble currents, often furnishes good results. 

Spermatorrhoea is usually found in connection with onanism, 
sexual excess, often with sexual perversion, in victims weakened by 
self-indulgence. The treatment calls for the exercise of much pa- 
tience and tact. The physician may accomplish more by elevating 
the standard of morals than by prescribing drugs. The condition of 
many of these patients is pitiful. They have been led to believe that 
their lives are wrecked. They are finally frightened at shadows. 
They may be led out of these delusions only by kindness and encou- 
ragement. Ridicule or contempt drives them back to the charla- 
tans, vampires who feed on the miseries of their fellow-men. 



IMPOTENCE. 

Impotence (impotens, powerless) is a relative or absolute incapa- 
city for natural coitus. It depends upon physical, toxic, and psychi- 
cal causes. Sexual potency, which is wholly relative and varies in 
degree in the same individual, ' depends on the integrity of a reflex 
loop to and from a special centre in the lumbar cord, but the activity 
of this centre depends, in turn, on cerebral and reflex influences. 
Cerebral centres normally exercise over the spinal centre inhibitory 
or controlling effects. In the absence or alteration of this influence 
the spinal centre acts to excess to produce priapism. Thus section 
or destruction of the cord above the lumbar region is often followed 
by powerful and continuous priapism, because the inhibition from 
the brain is cut off. Sometimes the inhibition is too strong and 
psychical influences prevent erections altogether (impotentia psy- 
chica). This control, or lack of control, is partly a matter of original 
endowment, and partly of habit. It is, at first at least, largely a 
matter of self-denial or self-indulgence. The originating or rein- 
forcing centres in the cerebrum may be cultivated to such degree 



676 IMPOTENCE. 

as to entirely overcome the inhibiting centres and make a man " a 
slave to his passions." 

Etiology. — Physical causes include malformation and defects, 
atrophy, tumors, etc. , which belong to the domain of surgery. Crypt- 
orchism (upvnro?, concealed — i.e., undescended — opxit, testicle) 
causes impotence only when both glands are atrophied. Mere reten- 
tion in the abdomen or in the inguinal canal is not incompatible with 
potency. Among physical causes are to be included also the effects 
of certain diseases of the brain and cord, the degenerations, and of all 
diseases which produce marasmus. Maladies which show impotence 
as an early sign are diabetes, diphtheria, and tabes dorsalis, and all 
cases should be studied first with reference to the existence of these 
affections. Tuberculosis pulmonum is an interesting exception to 
the rule that diseases marked by marasmus are attended with impo- 
tence. By far the most common physical cause is excessive venery 
or abuse, onanism. Regarding excess the rule of Luther may be 
remembered : "In der Woche zweier macht im Jahr ein hundert 
vier" (twice a week is one hundred and four times a year). 

The most common cause of sterility in the male is gonorrhoea, 
which blocks the efferent vessels and shuts off the spermatozoids. 

Toxic influences are the effects of certain drugs, alcohol, the 
bromides, the iodides, opium, camphor, salicylic acid, lupulin. 

Psychical causes are fear of failure, despair, dislike, aversion. 
Sexual perverts are often impotent with virtuous wives. The condi- 
tion shows itself, as an impotentia coeundi, in absence of desire, 
absence or incompleteness of erection, premature discharge ; and, as 
an impotentia generandi, in absence (aspermatism), diminution, or 
alteration of the seminal fluid, which when present may be scanty, 
watery, purulent, or bloody, and may contain motionless (azoosper- 
mia), few, or no spermatozoids. Gonorrhoea with epididymitis and 
occlusion of the vas deferens is, as stated, the most common cause of 
the last-mentioned condition. 

The prognosis is much more favorable in cases of psychical and 
toxic impotence than in the presence of defects or paralysis. 

Treatment. — Fear of failure is generally relieved by resolution 
with efforts at complete abstention. Excesses are usually cured 03- 
continence. In all cases the most essential element in the treatment 
of impotence is rest. Defective innervation, including anaesthesia at 
the sensory surface, is best stimulated by strychnia gr. j^-jj, and 
electricity, faradization and galvanization, with the negative pole at 
the spinal centre and the positive, urethral electrode introduced into 
the prostatic portion to the sensory (sexual) surface at and about the 
orifices of the seminal ducts. Aphrodisiacs, including cantharides, 
act only by irritation and suggestion. Suspension with extension of 



DIABETES MELLITUS. 677 

the spinal column, not longer than five minutes a day, often relieves 
the impotence of locomotor ataxia. The deep injection of a strong 
solution, three to five per cent, of nitrate of silver is a powerful 
stimulant. 

The treatment of the psychical features or effects of impotence is 
the same as that of spermatorrhoea. 

DIABETES MELLITUS. 

Diabetes (Sia, through, fiaivoo, to go) mellitus (pteXi, Latin mel, 
honey). — A disease characterized by increase in the quantity of urine, 
and the continued presence of sugar in the urine, with disturbed 
nutrition, marasmus, liability to sudden coma, and a tendency to tu- 
berculosis. The disease receives its name, diabetes, from the first of 
these signs, the increased flow of urine. It is, however, often recog- 
nized in the absence of this sign, and the quantity of urine may vary 
to fall even below the natural amount in the course of, especially at 
the close of, the disease. The presence of sugar in the urine does not 
necessarily imply diabetes. Transitory glycosuria is common. It. is 
only when present in a 'certain amount, or more especially when per- 
sistent, that sugar in the urine indicates the disease diabetes. A 
variety distinguished by an increase in quantity, without sugar, is 
known as a special form — diabetes insipidus. 

History. — Celsus recognized the disease as a dangerous affec- 
tion, marked by increase of urine and emaciation. Aretaeus named 
the disease " diabetes'' and considered it a disease of the stomach. 
Galen located it in the kidneys, Sylvius in the blood. All this time 
the disease was known only by its main symptom, diabetes ; and, 
though the Indian physicians were familiar with the fact that the 
urine contained sugar, which they recognized by the taste, this 
fact was not known elsewhere until it was discovered by Thomas 
Willis (1674). Dobson (1775) seems to have been the first to obtain 
sugar from the urine, and with Pole, Home, and Cowley (1778- 
1788) to thus really distinguish the disease. Hollo (1797) now made 
the discovery, of inestimable value, of the relation to diabetes of vege- 
table food, which he banished from the dietary of patients in the 
treatment of the disease. Ambrosiani (1835) first demonstrated the 
presence of sugar in the blood, which Mialhe attributed to the dimin- 
ished alkalescence of the blood, recommending the administration 
of alkalies to substitute the deficit. Bernard (1850) produced sugar 
in the urine by a puncture of the floor of the fourth ventricle, and 
seemed to have established a nervous origin of the disease. Frerichs 
and Von Recklinghausen (1866) remarked upon the frequency in dia- 
betes of disease of the pancreas, which later writers bring in close 
connection with the origin of the disease. 



678 DIABETES MELLITUS. 

Etiology. — Diabetes has been attributed to disease of the stomach, 
kidneys, blood, nervous system, and pancreas. It has certainly been 
observed in connection with alterations of these various organs, but 
also without discoverable lesions in any. The real pathogeny of dia- 
betes is unknown. The disease is three times as frequent in men 
as in women, and occurs with especial frequency from twenty to 
fifty. Yet cases are occasionally observed in childhood, even as early 
as the first year of life ; and in age, even over seventy. Hereditary 
influence is sometimes pronounced. The disease is more frequent in 
the upper classes. The obese are especially predisposed ; according 
l to Pfeiffer thirty-three per cent of the obese become diabetic. Dia- 
betes has been observed to occur after traumata, especially after 
violent contusions or concussions involving the nervous system ; in 
the course of or after nervous diseases, insanity, epilepsy, tumors, 
aneurisms, etc. ; after emotional disturbances, fright, grief, anxiety ; 
and in the course of convalescence from infectious diseases, especially 
malaria. The disease in these cases is said to be symptomatic. 

Pathogeny. — The sugar which appears in the urine is derived 
from two sources : 1, from the food directly, or indirectly through 
the glycogenic function of the liver ; 2, from the blood, from trans- 
formation of the fats and albuminoids. In the first case the sugar 
disappears entirely upon absolute withdrawal of sugar and starch from 
the food; in the second case the sugar, though diminished in amount, 
still remains. Thus are to be distinguished two forms of diabetes. 

Morbid Anatomy. — No constant lesion is found in connection 
with diabetes. In the majority of cases nothing abnormal is found 
in the nervous system, including the vagus and the sympathetic. 
The liver is usually enlarged, but solely on account of hyperaemia. 
Statements concerning hyperplasia of liver cells and connective tissue 
are to be received with reserve. The kidneys are usually increased 
in size, also on account of hypersemia. The epithelium of the uri- 
nary tubules shows sometimes diffused inflammatory, more rarely 
fatty, change. The pancreas is affected more frequently. In nearly 
one-half of the cases it is found in a state of atrophy or degeneration. 
The disease of the pancreas has been attributed to affection of the 
coeliac plexus, which has also been considered a common cause of the 
disease of the pancreas and the diabetes. 

Symptoms. — Diabetes sets in insidiously, and, though usually 
preceded by dyspepsia and nervous signs — anorexia, nausea, head- 
ache, insomnia— is commonly recognized only when the patient no- 
tices an increase in the quantity of urine and thirst. Increased 
frequency of discharge is usually first observed at night, on account 
of the preoccupations of the day ; the quantity may vary from four 
pints to four quarts in twenty-four hours. 



DIABETES MELLITUS. 679 

The urine is clear, light in color, and free of sediment. It foams 
readily on shaking, and the foam persists. The reaction is always 
acid. The distinctive feature is the increase in its specific gravity 
up to 1030-1040, or even 1060. The specific gravity corresponds in a 
general way to the quantity of sugar and other solids present. A 
great excess of water may show a light specific gravity, 1008-1010, 
even in the presence of sugar. The quantity of sugar usually ranges 
at two to five per cent, but varies from the minimum, one-half of 
one per cent, to the maximum, ten per cent. 

For clinical purposes sugar is recognized by one of the following 
tests : 

1. Moore's Test. — To the urine in a test tube is added one-fourth 
of its volume of liquor potassse ; the upper part of the fluid is thor- 
oughly boiled. The presence of sugar is revealed by a brown color. 
The addition of an acid develops the odor of burnt sugar (caramel). 
The absence of coloration after thorough boiling is reliable nega- 
tive — i. e. , exclusive — evidence. 

2. Trommer's Test. — A ten-per-cent solution of sulphate of cop- 
per is let fall into the test tube containing the urine, drop by drop, so 
long as the copper dissolves. Liquor potassse is added in amount 
equal to the whole amount of fluid. The mixture is then slowly 
heated. The alkali, in the presence of sugar, deoxidizes the copper 
and precipitates the salmon-colored suboxide. The coloration should 
show before the boiling point is reached. It continues after cooling. 
When the quantity of sugar is small the test is rendered uncertain 
by the fact that uric acid and kreatinin show the same reaction. 

3. Nylander's Test. — Dissolve four grammes of Seignette salt in 
one hundred cubic centimetres of eight-per-cent potash solution, heat 
(but not to the boiling point), and add as much subnitrate of bismuth 
as will dissolve (about two grammes). Let cool ; filter. The clear 
solution is ready for use. 

Add one part of the Nylander solution thus prepared to ten parts 
urine. Boil for a few minutes. In the presence of sugar the mix- 
ture becomes first brown, then brownish-black or black from diffusion 
of the bismuth, which gradually sinks as a sediment. Minimal quan- 
tities require long boiling, five minutes, to precipitate a grayish sedi- 
ment, a mixture of earthy phosphates and bismuth. 

The test of Ny lander is among the most delicate and reliable of 
all. It discovers sugar in an amount as small as one-tenth of one 
per cent, and nothing natural to the body but sugar will give the re- 
action. Moreover, it is easily prepared and keeps almost indefinitely 
(Graber). It must be remembered, however, that certain drugs, the 
various modern antipyretics, with salol, senna, turpentine, will give 
the same result. 



680 DIABETES MELLITUS. ■ 

4. Fermentation Test. — Three test tubes are filled two-thirds 
full of mercury. To the first are added the suspected urine and pure 
yeast ; to the second, normal urine with yeast ; to the third, a dilute 
solution of sugar in yeast ; and to each tube a drop of solution of 
tartaric acid. All three tubes are now inverted, under cover of the 
thumb, into a vessel of mercury. The accumulation of carbonic 
acid gas at the top of the first and third tubes shows the presence of 
sugar. The second tube shows no displacement of its fluid. The 
quantity is roughly estimated by the specific gravity, provided the 
quantity of urine is increased ; more accurately from the difference 
in the specific gravity before and after the fermentation test. 

1. The rule runs : Divide the last two figures of the specific 
gravity by 4, and subtract from the quotient 1 or 2, according to the 
quantity of urine, the lesser number for a large quantity. Thus a 
specific gravity 1032 would give 32 -f- 4 = 8 — 1 or 2 = 6 or 7 per cent. 

2. Multiply the difference of fermentation by 0.22 ; the sum is 
the percentage of quantity. Thus, specific gravity before fermenta- 
tion 1032, after 1004, difference 28 ; and 28 X 0.22 = 6.16 per cent. 

The sugar commonly present is the variety known as grape sugar. 
Sometimes the urine contains other forms of sugar — inosite and levu- 
lose. Sometimes the urine contains products of fermentation, alco- 
hol, diacetic acid, and acetone, which is recognized by the Burgundy- 
red color struck on the addition of the chloride of iron. The urine 
may also contain albumin. The quantity of urea is markedly in- 
creased. The discharge of urine may be so frequent as to harass 
the patient. This is especially the case in childhood, where the sleep 
may be disturbed. Enuresis nocturna should always excite suspi- 
cion of diabetes. 

The thirst stands in correspondence with the quantity discharged. 
It is sometimes associated with a feeling of dryness, and is often 
insatiable. Suspicion of the existence of the disease may be excited 
by the constant endeavor of the patient to moisten the lips with the 
tongue. The gums are sometimes swollen ; they may bleed easily ; 
the teeth may become carious. The appetite is usually disturbed ; 
it may be voracious and yet fail to satisfy. The bowels are con- 
stipated. Nervous symptoms may assume prominence. There is 
usually progressive degradation of health and strength ; it is 
remarked in loss of energy, headache, disturbances of sensation, 
formication, other parsesthesise, severe neuralgia. The expression is 
usually nervous, anxious, troubled. A prominent symptom is im- 
potence ; patients frequently present themselves for treatment of 
this symptom, which is found to rest upon diabetes. The knee jerk 
is diminished or lost. Impotence, in association with absence of 
knee jerk, often leads up to the recognition of diabetes. On account 



DIABETES MELLITUS. 681 

of the excessive excretion of water the skin is dry and scaly. Pru- 
ritus, especially pruritus vulvae, is often distressing and obstinate, 
and scratching in its relief easily breaks the surface. A tendency to 
furunculosis is common, and the frequent occurrence of boils should 
always lead to examination of the urine. More extensive phleg- 
monous inflammations, even gangrene, occur in individual cases. 
The surgeon hesitates to operate upon the diabetic patient. Cata- 
ract occurs in five to ten per cent of cases, more especially in ad- 
vanced stages. The opacity of the lens is not due to loss of water, 
as was formerly believed, but to disturbance of nutrition. 

A peculiar coma is liable to supervene in the course of diabetes. 
It is the gravest of the nervous complications — in fact, is usually 
fatal. The patient, in the midst of his usual health, or that con- 
dition of it which belongs to diabetes, falls into somnolence and 
stupor, finally into coma. The coma supervenes sometimes sud- 
denly, and is attended with heart failure and collapse. In other 
cases it is preceded by nervous disturbances, headache, unrest, 
anxiety. It is commonly marked by a characteristic deep-sighing 
respiration, often by cyanosis. Occasionally the breath has a pe- 
culiar odor, sometimes fruity, sometimes suggestive of chloroform. 
The coma is attributed to an acid fermentation of the blood with the 
development of acetone, because it has been observed that the urine 
strikes the Burgundy-red color with the chloride of iron. But 
neither acetone nor other product of decomposition has yet been dis- 
covered in the blood. This complication may put an end to life 
in twenty-four hours, more frequently in the course of three to five 
days. 

Along with the general degradation of tissue connected with the 
formation of carbuncles, necroses, and gangrene, is a tendency to 
tuberculosis. Diabetes fertilizes the soil for the growth of the 
tubercle bacillus. One-half of ' all cases of diabetes succumb to 
tuberculosis. 

Course. — Diabetes is a chronic disease of varying duration. 
Cases are distinguished as diabetes acuta and even acutissima, which 
may run their course in a few weeks or months. The disease 
usually lasts from three to fifteen years ; the average duration of 
life ranges about five years. Forms are differentiated as light and 
severe, according as the symptoms may be controlled or not by diet. 
After the study of one thousand cases Seegen still insists upon this 
classification of cases. In the lighter form sugar disappears from 
the urine with abstinence from starch and sugar in the food, while 
in the severer form the sugar still persists. There are, he still main- 
tains, no mixed or other forms. The disease advances rather in 
stages than continuously, with periods of remission and exacerbation. 



682 DIABETES MELLITUS. 

The prognosis is always grave. Diabetes is not yet a curable 
disease. But the immediate outlook depends upon the form of the 
disease. Patients may in the lighter form live to die of old age, while 
life is always cut short in the graver forms. Diabetic coma is always 
an ominous sign, and tuberculosis has far greater gravity when it 
develops in the course of diabetes. 

The diagnosis depends upon the increased urine and the pre- 
sence of sugar. Sugar exists naturally in the blood in very small 
amount (0.1 to 0.3 per cent), and has been found in health in very 
minute quantities even in the urine. The existence of 0.3 per cent 
of sugar in the urine suffices to produce all the signs of grave dia- 
betes (Abels). It is the persistence of sugar in the urine in distinct 
quantity that distinguishes diabetes. The general degradation of 
strength, dyspeptic signs, pains and parsesthesiae, furunculosis, 
pruritus, disturbances of vision, excite suspicion of the existence of 
diabetes, which can only be declared positively by the discovery of 
sugar in the urine. 

Treatment is mainly a matter of diet. Sugar and starch must 
be withheld. The food should consist largely of milk and meat, 
every form of which, in fish, flesh, and fowl, may be allowed. Vege- 
tables which contain much starch must be taken sparingly or put 
under ban. Certain vegetables may be given freely — lettuce, cress, 
made into salad ; cucumbers, tomatoes (raw), spinach, asparagus, 
string (green) beans, cabbage, and cauliflower. But beets, peas, 
beans (butter beans and dried beans), potatoes, corn, rice, cereals, 
are prohibited foods. Coffee and tea may be sweetened with a pinch 
of saccharin, which is three hundred times as sweet as sugar and 
does no damage. Levulose is said to be a sugar which acts without 
injury as a food. The denial of bread and potatoes becomes a 
punishment. Patients crave bread. The so-called health foods — 
flour from which the starch has been removed, almond flour, etc. 
— are poor substitutes. It is better to allow small quantities of 
bread regularly or occasionally. The object in the treatment of dia- 
betes is not so much to secure urine free from sugar as to maintain 
the patient in a state of health, as near as may be. It is better to 
maintain the health with a certain glycosuria than to lose it without 
glycosuria. Of forty-nine cases treated by Liebermeister under 
withdrawal of all carbohydrates, the sugar disappeared entirely in 
twenty. In seven of these cases it reappeared with return of the 
patient to the use of starchy food ; in two, only when the food was 
taken in excess ; in five, only when white bread was taken in quan- 
tities exceeding four ounces per day. 

Drugs can accomplish little. Opium distinctly reduces the quan- 
tity of sugar and diminishes the quantity of urine ; but it also dis- 



DIABETES IXSIPIDrS. GS3" 

turbs digestion, and may therefore be resorted to only temporarily 
in extreme cases. In prolonged use its evils counterbalance its good. 
Pavy preferred codeine in dosage increased from three to thirty 
grains a day. But the same objections as to opium apply eventually. 
Rational therapy is out of the question until the nature of the disease 
is understood. On account of the acid condition of the urine and 
the assumed reduced alkalinity of the blood, alkalies, especially in 
the form of mineral waters — Vichy and Carlsbad — may be adminis- 
tered freely. The salicylate of soda or salol, ten to fifteen grains 
four times a day, may be given with much temporary benefit. Ar- 
senic, Fowlers solution, gtt. iij.-v. three times a day, best supports 
the general nutrition. Dyspeptic signs are relieved by regulation of 
the diet. Xux vomica, tincture, gtt. x.-xx., is indicated in failing 
appetite. Thirst may be relieved by drinking less water at a time, 
frequent washing of the mouth, the use of ice pills, and chloroform 
gtt. ij.-iij. In diabetic coma the blood may be saturated with alka- 
lies, especially the bicarbonate of soda. The salt solution (common 
salt one drachm, bicarbonate of soda gr. xlv., water one pint), 
sterilized by heat and cooled to 100° F., may be introduced into the 
veins. Diabetic patients should dress warmly, guard against expo- 
sure, and avoid both inactivity and excess. Travel aggravates the 
disease. 

DIABETES INSIPIDUS. 

Diabetes insipidus is an increase in the quantity of urine without 
the presence of sugar — a polyuria without glycosuria. But every 
polyuria does not constitute this form of diabetes, for polyuria is a 
necessary result of the ingestion of large quantities of fluid. Ex- 
cesses of fluid — water, milk, beer — are discharged in this way. Poly- 
uria occurs also in connection with certain forms of kidney dis- 
ease — renal cirrhosis, where it is due to disease of the glomeruli, as 
well as to increased forcing power of the heart. Bernard found that 
irritation of a point in the floor of the fourth ventricle a little above 
the diabetic point produces polyuria without glycosuria. On this ac- 
count the disease has been referred to nervous origin and considered 
a subvariety of pure diabetes. But diabetes insipidus has nothing in 
common with diabetes mellitus, except increased quantity of urine ; 
for diabetes insipidus is not attended with the general signs — dys- 
pepsia, neuroses, pruritus, cataract, marasmus — of diabetes mellitus. 

In the present stage of knowledge diabetes insipidus is considered 
a vaso-motor neurosis, probably of central origin. 

Etiology. — Notwithstanding the essential difference in the na- 
ture of the affections, the same obscurity surrounds the origin of dia- 
betes insipidus. The condition has been noticed to occur in the- 



684 DIABETES INSIPIDUS. 

course of organic brain disease after trauma and emotional distress. 
It has also been attributed to exhaustion and exposure to cold. The 
influence of heredity is sometimes marked. "Weil reported twenty- 
three cases of diabetes insipidus in a family whose various branches 
numbered ninety-one persons. The disease is more frequent in the 
male sex and about the period of maturity. 

Symptoms. — The symptom is the increase in the quantity of 
urine, which may be slight or great. The quantity may vary from 
four pints to four quarts, and not infrequently exceeds this amount. 
The urine is clear and light, 1005 and less. Thirst increases in cor- 
respondence with the loss of water, though it is not so intense and 
insatiable as in diabetes mellitus. The secretion of sweat, including 
the insensible perspiration, is reduced or arrested — a point of great 
value in differential diagnosis, for the action of the skin is unaf- 
fected in the polyuria of health, hysteria, etc. The general health 
may be sustained throughout. The disease is chronic and runs its 
course with remissions and exacerbations. It is often arrested for 
months at a time and is not infrequently absolutely cured. Treat- 
ment consists in regulation of life. Water must be taken frequently 
rather than abundantly. Opium has the same effect as in true dia- 
betes in producing immediate effect with the same remote evil. Er- 
got sometimes controls the condition. Antipyrin, antifebrin, and 
agents of this class quickly reduce the secretion. The preparations 
of zinc, the lactate and valerianate, sometimes exercise more per- 
manent effects. Arsenic in the form of the common potash solution, 
gtt. iij. ter die, or with bromide, as the solution of the arsenite of 
bromine, in the same dose, should be given faithful trial in every 
case. 



DISEASES OE THE 

NERVOUS SYSTEM. 



CHAPTER XL 

DISEASES OF THE NERVES AND MEMBRANES. 

Diseases of the nervous system are distinguished as organic 
with discoverable, and functional with undiscoverable, lesions, and 
make themselves manifest by alteration of sensation, as abnormi- 
ties, paraesthesia ; loss, anaesthesia ; increase, hypersesthesia ; pain, 
neuralgia ; disturbance of nutrition, trophic change ; alteration of 
motion ; spasm, contraction, paralysis, abnormity of reflex ; affec- 
tion of special sense, intellectual faculties, and of consciousness. 

NEURALGIA. 

Neuralgia (vsvpov, nerve, aXyoz, pain), pain of nervous origin. — 
A symptom, not a disease, due to affection of the nerve at its centre, 
in its course, or at its distribution. The lesion may be gross and dis- 
coverable (i.e., organic) or merely molecular (i.e., functional). 

Etiology. — Neuralgia may depend upon irritation of the nerve by 
trauma, exposure of the nerve (toothache), or pressure. Wounds of 
all kinds, aneurism, hernia, exostoses, cicatrices, etc., may be the 
exciting cause. More frequently neuralgia is due to poisoning of the 
blood by infection (malaria), products of inanition, exhaustion as 
from anaemia, chlorosis, loss of blood. Neuralgia is rare in child- 
hood, and is much more frequent in women than men. 

Symptoms. — As the name indicates, neuralgia is distinguished by 
pain, which varies in every degree of variety from a dull headache 
to the excruciating paroxysms of tic douloureux. The pain is con- 
fined to the nerve affected, trigeminus, sciatic, etc., or irradiates 
from its origin in various directions, as in angina pectoris. It is some- 
times reflected or projected to a distant point, as in pain of the knee 
from coxalgia. Severe paroxysms are attended by general distress, 
nausea and vomiting, sinking signs, sometimes by muscular spasm. 



#86 NEURALGIA. 

Severe pain is paroxysmal for the reason that sensation becomes 
•exhausted for a time. 

Neuralgia of the Trigeminus occurs in its various branches as 
supra- and infra-orbital and as supra- and infra-maxillary neuralgia. 
Painful points may be detected on pressure at the orifice of exit 
of these various branches. Infra- orbital neuralgia occurring in par- 
oxysms causes the excruciating pain in the side of the face known as 
tic douloureux. Supra-orbital neuralgia is most frequently due to 
malarious or rheumatic cause. The other forms may be caused 
by affection of the teeth, pressure upon nerve trunks, degenerative 
lesions of ganglia or nerve cells at their deep origin. 

Occipital Neuralgia, manifested by pain in the back of the 
head, is also a common expression of malaria or other toxemia. 
Typical cases have been observed in connection with the absorption 
of toxic substances from the uterus and prostate gland or posterior 
urethra. 

Intercostal is a common form of neuralgia. It is usually felt 
in the neighborhood of the nipple, and more frequently upon the left 
side. It is a common expression of Bright's disease, but may be 
due also to malaria, where it must be distinguished from rheuma- 
tism, and to tuberculosis, where it must be distinguished from pleu- 
risy. Intercostal neuralgia distinguishes itself by its three painful 
points: (1) near the spine, where the nerve issues from the interver- 
tebral foramen; (2) near the axillary line, where the nerve becomes 
subcutaneous; (3) near the sternum, where the terminal branches 
become subcutaneous. A n eruption (herpes) in the course of these 
nerves is not uncommon. , 

Sciatica. — Pain in the course of the sciatic nerve is so frequent 
as to be considered as a separate affection. It is sometimes evidence 
of organic disease, especially of caries of the vertebra, and the sim- 
ple neuralgic affection must be distinguished from the pain of pres- 
sure, as from coprostasis, tumor, aneurism, etc. The cause of sci- 
atica is often obscure. It is more frequent in men than women, and 
in the lower classes where the condition is often confounded with 
rheumatism. Sciatica is much more frequently excited by local 
cause, cold and damp, and is much less frequently due to general 
cause, malaria, Bright's disease, etc. Painful points may be some- 
times discovered, especially in the neighborhood of the tuberosity of 
the ischium; in the course of the trunk of the nerve; lower, in the 
ham, behind the head of the fibula, over the foot. It is sometimes 
attended with cramp, and is more frequently than any other form 
associated with atrophy of muscle. The pains of sciatica are, as a 
rule, more continuous than acute, and stand in closer relation than 
other forms to climatic change. 



NEURALGIA. 687 

Coccyodynia is an obstinate neuralgia of the coccygeal plexus, 
which occurs especially as a traumatic lesion in connection with par- 
turition, less frequently from unknown cause, exposure to cold, etc. 
It may be so severe as to require resection of the nerve or even extir- 
pation of the coccyx. 

Headache (cephalalgia) is the most common of all the forms of 
neuralgia, and may be an expression of all the multitude of causes 
which may produce neuralgia in any form. Headache announces 
the advent of the acute infections. Persistent headache in an indi- 
vidual previously free from it should excite suspicion of B right's dis- 
ease. A localized, circumscribed point of pain (clavus) is a frequent 
expression of hysteria. 

A special form, of periodic occurrence, found usually in connection 
with disturbance of the stomach, constitutes the variety known as 
sick-headache (migraine), which is variously interpreted as a vaso- 
motor (sympathetic) disturbance, or neuralgia of the intracranial 
branch of the trigeminus. Migraine is transmitted by heredity di- 
rectly, or is an expression of an allied neurosis — hysteria, epilepsy, 
insanity — and consists, with them, of an underlying state and explo- 
sion from exciting cause. It runs in families, and appears in women, 
in whom it is by far most frequent, especially in connection with 
menstrual disturbance. 

It occurs in paroxysms without distinct periodicity, though some- 
times quite regularly with menstruation, sometimes again twice a 
month, or several times only in the course of the year. It is espe- 
cially wont to occur in connection with emotional disturbances. 

The attack begins usually in the morning, upon awakening after 
a night of restlessness or heavy sleep, with malaise, depression, 
irritability, and the headache supervenes at once as a dull distress, 
sometimes diffuse, usually localized in one or the other, more fre- 
quently the left, side of the head. f The pain is sometimes confined 
to the region of individual nerves, especially in connection with pa- 
rietal and supra- orbital branches, and varies in every degree of inten- 
sity. The special senses are hypercesthetic : light pains the eyes ; 
scotoma is common ; crenellated outlines more rare ; noises otherwise 
unnoticed inflict punishment ; odors excite nausea. Disturbance of 
the stomach assumes such prominence as to have given the common 
name to the disease, sick- headache. It is not the cause of the head- 
ache or neuralgia, but is a coeffect of a common cause. Vomiting 
occurs frequently, with discharge of the contents of the stomach, or, 
as the stomach is usually empty, of accumulated mucus and regur- 
gitated bile. The face on the affected side is usually flushed, and 
branches of the temporal arter}- throb visibly in their tortuous course. 

Diagnosis. — Migraine is distinguished from epileptic forebod- 



688 NEURALGIA. 

ings by the stomach distress and preservation of consciousness, and 
from Bright's disease, renal cirrhosis, by the absence of albuminuria. 

The treatment is usually successful at first, but fails later with 
the same remedy. Rest in bed, with perfect quiet of mind and body, 
is the first essential. Every case requires study for the discovery, 
and if possible removal, of some distinct cause, as anaemia, dyspepsia, 
irregular habit, insufficient sleep, mental strain, excess in social life, 
domestic trial, etc. The attack proper is relieved or curtailed by the 
bromides in large doses, gr. xxx.-xl. in a glass of water, caffeine 
gr. ij.-iij., guarana gr. xxx., the powder of coca leaves gr. xv., 
cocaine gr. ss., antipyrin gr. v.-x. Any of these remedies may 
succeed at first, but with increasing tolerance fail in later attacks. 
The only real success is accomplished by address to the underlying 
state. Increase in the general health prolongs the interval and re- 
duces the severity of the attacks. Change of climate often gives re- 
lief. Change of occupation may have the same effect. The attacks 
cease sometimes with the grand climacteric in women and at the 
corresponding period of life in men. Sometimes they remain in 
greater or less severity, defiant of all medication, as a life-long evil. 

Gastralgia, neuralgia of the stomach, has already been described 
in connection with disease of the stomach, and neuralgias of the 
heart, palpitation, angina pectoris, etc. , in connection with disease of 
the heart. 

Enteralgia, neuralgia of the intestine, nervous colic, depends 
upon the same causes as gastralgia. It occurs especially in nervous 
individuals, and alternates with other forms of neuralgia. It shows 
itself also in other cases independent of other neuroses or of a neuro- 
pathic temperament, as the result of a toxaemia. A typical example 
of this enteralgia is furnished in lead colic, where the disease is due 
to the direct effect of lead upon the ganglionic centres. As in gas- 
tralgia, the pain may be very severe and may be attended with 
sinking sensations, vomiting, heart failure, and collapse. Hot appli- 
cations, including copious injections of hot water, with the admin- 
istration of anodynes, morphia subcutaneously, relieve the attack. 
The cause, when rheumatic, is most effectively addressed by salicylic 
acid in doses of gr. x. every hour or two until the ears ring. The 
remedy must be administered continuously at longer intervals for a 
week. Lead poisoning calls for appropriate treatment. 

Neuralgia of the Spermatic Nerve occurs more especially 
in the young, and shows itself in shooting pain which radiates from 
the testicle along the course of the spermatic cord. It may be also 
associated with nausea, vomiting, and sinking sensations. The 
treatment is the same as that of the neuralgias just mentioned. 

Neuralgia of the Joints occurs especially in connection with 



NEURALGIA. 689 

hysteria, and is sometimes one of the most obstinate manifestations 
of that disease. It is usually confined to a single joint, the hip or 
knee, and may show itself with all the signs of acute rheumatism, 
including at times redness of the skin. It is sometimes attended 
with deformity and atrophy from disuse. The diagnosis is often 
difficult, but is assisted by consideration of the age, sex, and history. 
The hysterical joint occurs in connection with other signs of hyste- 
ria. The sensations of pain and distress are out of all proportion to 
the objective signs, etc. 

The treatment of neuralgia consists in the discovery and removal, 
if possible, of the cause. This cause is often, as stated, an infection 
of the blood, and treatment consists in the neutralization of the pro- 
ducts of infection. Thus quinine and arsenic quickly cure the most 
obstinate cases of malarial neuralgia, and mercury and iodide of 
potassium cure or control the pains of syphilis. Neuralgias of the 
stomach and bowels, gastralgia and enteralgia, are usually relieved 
by salicylic acid or salol; the neuralgic pains of Bright's disease are 
best controlled by hot baths and remedies which produce sweating — 
jaborandi, pilocarpine. More permanent effects are obtained by the 
use of mineral waters, sojourn at watering places, etc. Neuralgias 
which depend upon alterations of the blood — anaemia, chlorosis, etc. 
— are treated with some of the various preparations of iron, as men- 
tioned under Chlorosis, etc. The various antipyretics — phenacetin 
gr. x., antipyrin gr. v., antifebrin gr. v. — give sometimes immediate 
effects. Counter-irritation, especially in the form of linear cauteri- 
zation, may control obstinate cases of neuralgia in the neighborhood 
of the spine. The remedy of most value for general use is electri- 
city, which may be used in the form of the induced or constant 
current. The negative pole is applied usually to the spine in the 
neighborhood of the origin of the nerve; the positive is stroked 
gently along the course of the nerve, or is held fixed for five minutes 
at the seat of pain. Gentle currents which produce only redness of 
the surface are attended with the best effects. 

Atropine (gr. i.— 3 i.) gtt. hj.-v., hyoscyamine gr. yi^, are effec- 
tive anodynes. Sometimes a severe neuralgia is relieved at once by 
injection into the substance of the nerve, with the subcutaneous 
needle, of chloroform or ether gtt. v.-x. This procedure proves of 
most value in cases of sciatica. Morphia should be used only as the 
last resort in extreme cases. The evils of the opium habit are mostly 
engendered by resort to morphia in relief of neuralgia. 

The treatment of neurosis of the joints is that of the general 

rather than the local condition, whereby it is often best to ignore the 

joint affection as much as may be, for concentration of attention 

upon it often aggravates the malady. Isolation of the patient, or, 

44 



690 NEURITIS. 

better still, occupation of a bed in a hospital ward by the side of 
cases of real maladies — other than joint diseases, of course — accom- 
plishes more than local treatment. Nevertheless massage, manipu- 
lation, hydrotherapy, electricity, salol, are sometimes of value. 

NEURITIS. 

Neuritis. — Inflammation of nerves, attended by hypersemia, infil- 
tration, and degeneration. Neuritis may be acute or chronic, fixed 
or wandering, ascending or descending in the course of the nerve. 

It is usually due to trauma, though it may result from extension 
of inflammation from contiguous structures. Thus an ascending 
neuritis is sometimes seen to develop in consequence of an infection 
of the genito-urinary organs. A good example of a descending neu- 
ritis is found in connection with changes in the spinal nerves issuing 
f rorn a cord affected with locomotor ataxia. The neuritis produced 
by the action of toxines — diphtheria, typhoid fever, etc. — is a pro- 
cess better known in its effects than its lesions. The peculiar infec- 
tion of the tropics known as beriberi and kakke (Japan) is regarded 
as a panneuritis. This disease is associated with heart failure, with 
parsesthesise, numbness and burning, and paralysis. Neuritis some- 
times follows exposure to cold. This form is known as rheumatic. 
It occurs also in connection with syphilis, lepra, cancer, and gout. 
Multiple neuritis is often distinctly caused by alcohol. The pains of 
neuritis differ from those of neuralgia, in that they are more contin- 
uous and are aggravated rather than lessened by pressure. They 
are also associated with more or less anaesthesia. Muscles in the 
domain of the affected nerve lose their electric excitability and show 
later the reaction of degeneration. Trophic changes sometimes de- 
velop ; herpes zoster is common. A much more rare trophic change 
is the perforating ulcer of the foot, malum perforans pedis, which 
develops as a progressive ulcer, uncontrollable in its progress, on the 
sole of the foot. 

Multiple Neuritis distinguishes itself by the affection of a 
number of nerves, usually consecutively. It results, as stated, 
chiefly from alcoholism, and is the common cause of alcoholic para- 
lysis. It occurs, however, in connection with exposure to cold, 
rheumatism, and exhaustion ; sometimes as the result of toxsemia. 
The musculo-spiral and anterior tibial nerves are usually first af- 
fected. The wrist drops, the feet are extended to lie on a line with 
the legs. The disease begins, as a rule, with fever and sensations of 
numbness and tingling in the fingers and toes, with more or less rheu- 
matic pain. The nerve trunks are sensitive to pressure. The power 
of extension of the hand is impaired in both arms. The same weak- 
ness soon shows itself in the legs. Electric excitability is lost and 



SPASM. 691 

the muscles show the reaction of degeneration; reflex action is also 
lost : the knee jerk disappears early in the history of the disease. 
Trophic changes, oedema, and joint effusion are common ; the 
sphincters are unaffected. The disease is chronic, and advances, as 
a rule, more or less continuously for a period of four to six weeks, 
when it slowly subsides. Complete restitution requires a period of 
many months. In the alcoholic form of the disease relapses are fre- 
quent. 

Treatment. — The asepsis of modern surgery prevents many cases 
of neuritis. Prompt and more persistent treatment of gout and 
syphilis has the same effect. The pains of acute neuritis may be 
relieved by the methods used in the treatment of neuralgia. Coun- 
ter-irritants are of more decided value. Hot applications, dry cups, 
tincture of iodine, cauterization, vesicants, may be used in individ- 
ual cases. The preparations of salicylic acid are of especial value 
in rheumatic, febrile, and alcoholic forms of the disease. Alcohol 




Fig. 276.— Multiple (alcoholic) neuritis : palsy of extensors of wrist and flexors of ankle (Gowers). 

itself must be put under ban. The body must be built up with 
quinine, cod-liver oil, tonics, fresh air, and good food : the affected 
nerves with electricity and strychnia. 

SPASM. 

Spasm may be of central or peripheric origin. It occurs as more 
or less continuous (so-called tonic) and as interrupted (so-called clo- 
nic) convulsions. Examples of tonic convulsions are furnished in 
tetanus, tetany, cramp (cholera), contractures (post-hemiplegic, etc.). 

Myotony, a peculiar form of contraction, was first described by 
Thomsen (1876), as experienced in his own person. It is, hence, 
often known as Thomsen's disease. In this affection the muscle, in- 
stead of being relaxed after effort, remains in a state of tonic con- 
traction for some length of time. The disease may even involve the 
muscles of the tongue. In a curious case recorded by Ballet and 
Marie the eyes became fixed, and were only changed with difficulty 
from the direction which they were made to assume. 

Torticollis (caput obstipum) is the most common example of 



692 PARALYSIS. 

tonic spasm. The muscles usually affected in this condition are the 
sterno-cleido-mastoid, the splenius, and the trapezius. The head is 
rotated to one side and the face is turned up. Distinction must be 
drawn between cases which originate from simple exposure to cold, 
so-called rheumatic affection of the muscles, and conditions due to 
diseases of the spinal cord or vertebrae, as caries of the spine. The 
rheumatic affection may give rise to much pain and distress, but is 
of short duration. It disappears readily under faradization, hot ap- 
plications, anodynes, stimulating liniments, etc. 

R Tincturse opii, tincturae aconiti, olei olivae aa p. se. 

M. S. Liniment. 

Pain may be relieved by the use of atropia gr. T £ ¥ , or hyoseya- 




Fig. 277.— Spasm of the trapezius (Duchenn^). See also page 323. 

mine gr. T ^ ¥ , subcutaneously. Cases due to organic disease are ex- 
ceedingly obstinate, sometimes irremediable. Section and exsection 
of the nerve afford only temporary relief. Better results may be 
reached by exsection of a series, as of the first three cervical nerves, 
after the method suggested by Keen. 

Lumbago, which is interpreted as a rheumatism of the muscles 
of the loins or lumbar region of tener than as a peripheral nerve af- 
fection, may be so severe as to demand the injection of morphia gr. J 
deep into the substance of the muscles. 

PARALYSIS. 

Paralysis {napaXvco, to loosen) may be central or peripheral. It 
shows itself as impairment or abolition of motion. Partial para- 
lysis is sometimes distinguished as paresis. Paralyzed nerves 



PARALYSIS OF THE FACIAL NERVE— BELLAS PARALYSIS. 693 

degenerate. This degeneration is marked by certain changes in elec- 
trical irritability. In the normal nerve the application of the 
negative pole, cathode, produces contraction at the moment of clos- 
ing, and of the positive pole, anode, at the moment of opening the 
circuit. Healthy muscle, independent of the nerves, cannot be ex- 
cited to contraction by the induced (faradic) current, but may be 
excited to slow contraction by the constant (galvanic) current. 
When the nerves are degenerated the induced current fails to excite 
contraction when brought to bear either upon the nerves or upon the 
muscles ; and the constant current will not act upon the nerves, but 
will nevertheless produce a slow contraction in the muscle so long as 
the muscle itself has not suffered degeneration. For a certain pe- 
riod muscles supplied by degenerated nerves are more easily excited 
than muscles supplied by healthy nerves. Contraction occurs ear- 
lier and stronger, and the order of contraction is reversed. That is, 
the positive pole produces the strongest contraction with closing, and 
the negative with opening, the circuit. This change, which indi- 
cates a certain period of degeneration, is known as the reaction of 
degeneration. It is a valuable sign in both diagnosis and prog- 
nosis. 

Muscles supplied by degenerating nerve fibres are more sensitive 
also to mechanical irritation. A stroke upon the muscle, or exposure 
to cold air, excites contraction. Such idio-muscular contraction is 
seen in the muscles of patients suffering from marasmus from any 
cause, tuberculosis, carcinoma, etc., and is typically shown in the 
fibrillar contractions of progressive muscular atrophy. 

PARALYSIS OF THE FACIAL NERVE — BELL'S PARALYSIS. 

Paralysis of the facial nerve arises in consequence of disease or 
injury to the nerve at its origin, course, or distribution. The para- 
lysis is central or peripheral. Central paralysis occurs in con- 
nection with hemiplegia (haemorrhage, embolus), and is nuclear, su- 
pra- and infranuclear, according as the lesion is situated in, above, 
or below the pons. In supranuclear lesion the nerves about the 
mouth suffer most, and voluntary are more impaired than emo- 
tional movements, while electrical reaction remains normal. In nu- 
clear and infranuclear paralysis all parts of the face are paralyzed 
and secondary changes set in with reaction of degeneration. Injury 
in the intracranial course of the nerve is usually inflicted by menin- 
geal exudation and tumors. The condition is recognized by impli- 
cation of the auditory nerve. Disease of the ear, caries . of bone, is 
the most common cause of damage in the Fallopian canal. 

Etiology. — In the great majority of cases the lesion is peripheral, 
and is a form of neuritis, the result of exposure to cold. Paralysis 



694 PARALYSIS OF THE FACIAL NERVE— BELLAS PARALYSIS. 

is especially wont to set in after sitting in a draught, as at an open 
railroad car window, where the rest of the body is superheated. 
Syphilis affects the eye (oculo-motor, abducent) much more fre- 
quently than the face. Peripheral facial paralysis is sometimes 
observed in consequence of suppurative parotitis, and is not infre- 
quently produced in the new-born by the pressure of the forceps. 

Certain families, certain individuals (neurotic), are predisposed to 
the disease. 





Fig. 278.— Facial paralysi 
face (Putzel). 



left side, under attempt at contraction of all the muscles of the 



Paralysis is limited to one side, but is exceptionally bilateral, in 
consequence more particularly of disease of the pons, sometimes of 
diphtheria. 

Symptoms. — In complete paralysis of the facial nerve one whole 
side of the face becomes immobile. The muscles hang without ex- 
pression, so that the affected side looks like a mask. The contrast, 
which is marked even at rest, becomes more marked with the at- 
tempt to express an emotion. The contraction of the sound distorts 



PARALYSIS OF THE FACIAL NERVE— BELL S PARALVSIS. 



695 



the affected side. The eye is open and cannot be perfectly closed. 
The ball is rolled upward in protection against the light. The pa- 
tient is unable to lift the eyebrows, corrugate the forehead, move 
the side of the lips, show the teeth, whistle, or blow. On account of 
affection of the buccinator, food accumulates between the teeth and 
cheeks. With lesion at or above the geniculate ganglion one side of 
the palate is paralyzed ; it hangs lower than the other side, and is 
not lifted in articulation. The uvula deviates (is drawn) toward the 
sound side. Paralysis of the stapedius is taken advantage of by the 
tensor tympani to render the hearing more acute. In pure peripheral 
paralysis affection of the hearing is rare and the palate shows no 
deviation. Sensations of pain, sometimes experienced, are attributed 
to implication of sensitive fibres which run back in the course of the 
chorda tympani from the trigeminus. 

The important point in diagnosis is the differentiation of central 




Fig. 279.— Facial paralysis, patient aet. 65 ; showing loss of tone in inelastic skin. Figure on 
right represents attempt to close both eyes (Gowers). 



from peripheral lesion. Central lesion occurs, as stated, in connec- 
tion with hemiplegia of the same or opposite side, and the paralysis 
of the face is only partial. The patient can open and close the eyes. 
In central lesion reflex and associated movements remain and the 
muscles respond to the faradic current at any period. Peripheral 
lesion is more complete. The patient cannot open and close the 
eyes, and electrical irritability is diminished or lost. In peripheral 
affection the lesion is assumed to be intracranial when the auditory 
or other cerebral nerves are affected, or when the opposite side of the 
body is paralyzed. Paralysis of the palate speaks for lesion at or 
above the geniculate ganglion. The lesion is assumed to be in the 
Fallopian canal when it is found in association with otitis media, 
caries of the petrous portion of the temporal bone, and affection of 
the hearing. The lesion is superficial in the absence of these signs. 
The prognosis depends upon the cause. In the superficial 



696 MENINGITIS, SIMPLE CEREBRAL. 

(rheumatic), which is the most frequent form of the disease, the 
prognosis is good, and is chiefly determined by the electrical reac- 
tion. Any response to the induced current is a favorable indication. 
Such cases terminate with complete restoration in the course of a 
few weeks. In the absence of all response to the induced current, 
and of signs of the reaction of degeneration with the constant current, 
the course is more chronic ; recovery requires a period of several 
months. A few cases never recover. 

The treatment is the application of electricity in the form of the 
constant current, the negative pole behind the jaw under the ear, 
the positive stroked gently along the course of the facial muscles. 
The session, daily or tri-weekly, should not continue longer than five 
minutes. All other treatment is superfluous. The physician should 
never despair of relief so long as there is any kind of reaction to 
electricity. In the experience of the author, a young lady deformed 
by attack in childhood had the deformity greatly relieved by galvan- 
ization, though fourteen years had elapsed without any treatment at 
all. 

MENINGITIS, SIMPLE CEREBRAL. 

Pachymeningitis (naxv?, thick); leptomeningitis {XsnToS, thin); 
simple, as distinguished from cerebro-spinal and tubercular, menin- 
gitis ; meningitis of the convexity, as distinguished from basilar 
meningitis. — Meningitis, in general, was first recognized as an affec- 
tion separate from disease of the brain by Morgagni (1760). Epide- 
mic cerebro-spinal meningitis first attracted the attention of Vieusseux, 
of Geneva (1805), and of Strong, North, Fish, Hale, Miner, and 
Williams, of our own country (1806-1814), and had been at that 
early period easily differentiated from affections limited to the mem- 
branes of the brain. Parent-Duchatelet and Martinet (1821) first 
distinguished inflammation of the dura and pia mater, and Guerin 
and Guersant (1836-1839) first distinctly recognized and set apart 
the tubercular, granular, or basilar form of the disease. The first 
clear descriptions of the exclusively " simple" meningitis, from a 
pathological standpoint, are to be found in the works of Cruveilhier 
(1830); and from a clinical standpoint, in those of Andral (1834) and 
of Rilliet and Barthez (1843). The recognition of the fact that simple 
meningitis is always a secondary affection is the result of the more 
accurate post-mortem observations of the last ten years, in the light 
of the recent investigations concerning infections, and the contribu- 
tions from otology. 

Pachymeningitis, inflammation of the dura mater, presents itself 
in two forms, external and internal, purulent and hemorrhagic, 
representing entirely different disease processes. The first of these 



MENINGITIS, SIMPLE CEREBRAL. 697 

forms alone deserves the title or termination of the name, as it alone 
shows the signs and lesions of an inflammation, pachymeningitis 
externa, the haemorrhagic form, being really the result of a degene- 
ration rather than an inflammation; but in the absence of definite 
knowledge regarding the genesis of this disease, the two forms may 
be best studied together. 

Pachymeningitis Externa. — Accidents or injuries which di- 
rectly expose the dura, or effect its separation from the bones of the 
skull, with consequent extravasation of blood, whereby is implied, at 
least, a " hidden crevice" or some communication of the dura with 
the air, lead at once to inflammation of the outer lamella, which may 
extend to involve all the rest of the membranes of the brain. 
Carious processes of the ear constitute an even more frequent cause 
of this condition. A mere microscopic breach in the thin wall of 
bone that forms the upper covering of the tympanic cavity will bring 
pus from the tympanum to the dura. So, also, caries of the ethmoid 
bone (ozaena), or other bones of the cranium (syphilis, carbuncle), 
may excite this form of meningitis; and, even without caries, puru- 
lent inflammation of the mucosae in the ethmoid and frontal sinuses 
may extend to the dura through natural openings of communicating 
vessels. This complication has been noticed more especially in ery- 
sipelas after " mixed infection," whose nature it is to spread. As 
purulent pachymeningitis rarely remains confined to the dura, but 
extends, as a rule, to involve the pia mater, the symptoms, patho- 
logy, and treatment of this condition will be further discussed with 
leptomeningitis. 

Pachymeningitis Interna. — The disease of the dura which 
merits most consideration, from its frequency, limitation, and recog- 
nizability in life, is that affection of the inner layer characterized by 
the extravasation of blood and subsequent development of an adven- 
titious membrane, commonly known as haematoma durae matris, and 
technically described as pachymeningitis interna haemorrhagica. 
With these characteristics it is plain that internal pachymeningitis 
does not supply the requisite conditions nor rise to the nosological 
dignity of an inflammation in the modern sense of the term. It de- 
velops oftenest independently of all infection, and should properly be 
discussed as a subvariety of cerebral haemorrhage. 

The pathology of this affection remains as yet obscure. The 
early anatomists and clinicians were fain content with descriptions 
of the condition, without venturing to express opinions concerning 
the nature of the disease. It was commonly held and taught that 
the disease consisted in the extravasation of blood, and the only 
question discussed regarded its situation. Thus Abercrombie and 
Andral (1807) maintained that the blood was effused between the 



698 MENINGITIS, SIMPLE CEREBRAL. 

dura and the parietal layer of the arachnoid, so-called; while Hous- 
sard (1817) located the extravasation in what was then, and for the 
sake of convenience is still, known as the cavity of the arachnoid. 
The hemorrhagic nature of the affection was nearly lost sight of 
when Bayle (1843) considered the hsematoma as an inflammatory pro- 
duct of the dura, but was again restored by Durand-Fardel (1854), who 
believed in the development and organization of* a flat blood clot. 
Heschl (1855) regarded the membrane as a highly vascular connec- 
tive tissue, a view which Virchow, with his predilections for cellular 
pathology, elaborated into a hemorrhagic inflammation of the dura 
as the first process, and a subsequent infiltration of the blood as the 
second. The authority of these pioneers carried these views with 
almost undisputed conviction up to our own times, when the studies 
concerning the nature and processes of inflammation and infection 
naturally diverted attention to the condition of the blood and its ves- 
sels as prime factors in the production of the disease. 

That hsemorrhagic pachymeningitis is not the expression of an 
ordinary inflammation is shown by the fact that no amount of irri- 
tation of the dura will produce it. Injections of ordinary irritants 
into and beneath the membranes of the brain of lower animals may 
be followed by purulent, but never by hsemorrhagic, pachymeningi- 
tis. On the other hand, the injection of blood with all its constitu- 
ents sufficed, in the experiments of Sperling, to produce the typical 
signs and lesions of the disease. The role of the fibrin in these cases 
is evidenced by the fact that a membrane was not developed after 
injections of defibrinated blood. 

Internal pachymeningitis consists, then, in the extravasation of 
blood, the formation of a blood clot which, when the effusion is not 
too great or rapid, is flattened by pressure, to become subsequently 
organized into a membrane. In the first stage of the disease pro- 
cess the thin layer of coagulated blood soon begins to show, in the 
separation of its fibrin, a meshwork which contains multitudinous 
blood corpuscles. At this time there is no apparent connection with 
the dura, whose epithelium remains intact. In the consolidation 
which continues, the clot assumes the appearance and density of a 
membrane, which now in reality develops from the transformation 
of white blood corpuscles into spindle-shaped connective-tissue cells, 
whence the synonym pachymeningitis fibrinosa. The red corpuscles 
now gradually lose their coloring matter, which collects in spots on 
the surface and in the texture of the membrane (pachymeningitis 
pigmentosa), lose their regular contours, and finally become trans- 
formed into masses of protoplasm. Young vessels now connect the 
dura with the membrane, which becomes gradually more dense, 
thick, and adherent. In the meantime new layers of blood may be 



MENINGITIS, SIMPLE CEREBRAL. 699 

effused into the membrane already in process of formation, which 
consists thus of superimposed lamellae — Virchow has seen as many 
as twenty — for a time separable from each other. The effusion takes 
place chiefly upon the convexity of the brain, limited, in fifty-four of 
sixty-five cases collected by Kremiansky, quite precisely to the region 
covered by the parietal bones. It is rather more frequently bilate- 
ral than unilateral, being confined to one hemisphere in but forty- 
four per cent of cases. 

The source of the haemorrhage still remains a matter of dispute 
and doubt. Kremiansky thought it came from the middle menin- 
geal artery, an origin which comports well with the situation of the 
clot; but Huguenin declares that he has never seen this vessel af- 
fected in any of his observations. This author is inclined to find the 
lesion in the veins which run from the cortex to the longitudinal sinus 
along the falx cerebri ; and Pacchionian vessels have likewise been 
accused, but all alike without as yet satisfactory anatomical proof. 

The chief danger of these effusions is pressure upon the brain, 
which shows itself in proportion to the amount of the extravasation. 
Huguenin has seen a hemisphere flattened by a large unilateral 
haematoma, which may be as large as a hen's egg — Eichhorst men- 
tions effusions of five hundred grammes — and in some cases a lateral 
ventricle has been reduced by pressure to half its size. The great 
evil of pressure is obviated in many cases by the latitude allowed by 
atrophy of the brain substance, a condition rather, as a rule, coin- 
cident with haematoma of the dura. In fact, the greatest contingent 
of cases is found in connection with paralytic dementia, and cases 
independent of some degree of atrophy are comparatively rare. 

When, from any cause, a real inflammation is engrafted upon 
this haemorrhagic degeneration, serum or pus may be found in con- 
nection with the blood which forms the haematoma. As curiosities 
in this direction, Virchow describes a hydrocephalus externus pachy- 
meningiticus, and Weber saw, in a lamellated haematoma, blood in 
one cavity and yellow-green pus in another. 

Various changes in the skull membranes and brain have been 
observed in connection with pachymeningitis, but none so frequently 
as to belong to it of necessity. Thus the bones have been found 
thickened or thinned, with an agglutinated dura at times, the pia. 
anaemic, hyperaemic, and swollen, or cloudy and opaque, separable 
or adherent to the dura, etc. The frequency with which general 
atheroma of the cerebral vessels is seen, with thromboses, soften- 
ings, apoplexies, scleroses, etc., of the brain, bespeaks the intimate 
relation of these processes to the development of the disease, in con- 
nection more especially with general paralysis, alcoholism, insanity, 
senile atrophy, etc. 



700 MENINGITIS, SIMPLE CEREBRAL. 

Pachymeningitis is a much more frequent affection than is com- 
monly believed. Savage records its presence in three per cent of 
the autopsies made at the asylum at Bethlehem ; and when it is re- 
membered that there are more cases of dementia and insanity, not 
to mention alcoholism, out of than in asylums, it is seen that this 
percentage is far too low. It is safe to say that most of the cases 
remain undiagnosticated during life ; and death, when it occurs, 
though perhaps caused by this affection, is ascribed to the disease in 
the course of which this accident develops. All authors agree in 
noting three-fourths of all the cases in the male sex, a proportion 
-which corresponds to the relation of the sexes to the affections which 
produce the disease. For the same reason hemorrhagic pachymen- 
ingitis is a disease of advanced life. Exceptional cases at early 
periods of life — six months to eight years — have been recorded by 
Weber, Moses, Steffen, and others, mostly in connection with the 
venous stases from the strain of asthma, pertussis, etc., or the im- 
poverished nutrition of blood vessels from scurvy, leukaemia, and 
more especially pernicious anaemia ; and cases have been more 
abundantly reported during adolescence and maturity in connection 
with tuberculosis, empyema, valvular lesions of the heart, the vari- 
ous forms of Bright's disease, the various infections (variola, scarla- 
tina, acute articular rheumatism, and typhoid fever), and more es- 
pecially local injuries of the dura (seventeen of seventy-four cases 
described by Schneider) ; but, aside from these accidents, pachymen- 
ingitis remains a disease of age. The largest number of cases, 
twenty-two per cent, in the collection of Huguenin, occurred be- 
tween the ages of seventy and eighty. 

Symptomatology. — Internal pachymeningitis exists at times with- 
out a symptom to mark its presence. Moses reports such a case in 
a child, aged seven months, who died of catarrhal pneumonia. At 
the autopsy there was found a pachymeningitic cyst which covered 
the anterior half of the right hemisphere, though no sign of brain 
disease had ever been manifest in life. Slight extravasations often 
show no sign because of absence of pressure, or, if slowly effused, 
because of tolerance, which the brain acquires often in astonishing 
degree. In other cases the accident is overshadowed by symptoms 
pertaining to the original disease. These are, however, all exceptional 
cases. As a rule the disease may be diagnosticated during life by 
signs which are not so valuable in themselves as in their etiological 
relations. 

In the majority of cases the disease announces itself suddenly and 
violently. The patient is stricken with apoplexy. The haemorrhage 
may be so great as to cause death by compression of the brain with- 
in forty-eight hours. The nature of the disease, or, more strictly, 



MENINGITIS, SIMPLE CEREBRAL. 701 

the localization of the haemorrhage, is, as a rule, in such cases 
impossible to determine. The first attack is not, however, usually 
fatal. In exceptional cases the patient may recover fully, but as a 
rule a train of symptoms ensue which more or less distinctly charac- 
terize the disease. These symptoms vary greatly in individual cases, 
vary according to the locality and extent of the effusion, as well as 
according to the nature of the original disease ; but they do not dif- 
fer in essential characters from the symptoms of meningitis from 
any cause. Headache, stupor, which may at any time deepen to 
coma ; monoplegias, hemiplegias, or, in the irritant stage, unilate- 
ral tiuitchings and convulsions, limited at times to one extremity, 
or confined to the area of distribution of the facial nerve ; aphasia , 
when the region of the language centre is compressed — these symp- 
toms, together with an irregular or retarded pulse, vomiting, and 
more especially contracted or dilated pupils irresponsive to light, 
with little or no disturbance of general sensation, make up a group 
which, as a rule, distinguishes the disease. 

But, as already intimated, it is not so much the symptomatology 
of the affection as its etiological relations which strictly define the 
disease. The general signs of meningitis refer especially to haema- 
toma only when they occur in the course of general paralysis, chronic 
psychoses, alcoholism, chronic Bright's disease, pernicious anaemia, 
traumata, the affections mentioned in the discussion of the etiology 
of the disease. 

Another distinguishing, but by no means so distinctive, feature 
to indicate the nature of the affection is the recurrence of the symp- 
toms. Total or partial recovery from all the general manifestations 
of meningitis is followed in pachymeningitis, as a rule, by repeated 
attacks; and though the special symptoms may show great variety in 
relapses or recurrent attacks, the general character of the new signs 
is definitely sustained. 

The diagnosis of pachymeningitis is based upon these two cardi- 
nal points: the existence of an underlying condition or causative 
disease, and the more or less rapid recurrence of the attacks Cases 
are further characterized by suddenness of onset and rapidity of 
recovery. The author had under observation an individual affected 
with chronic alcoholism, who was suddenly stricken with apoplexy 
on the street. The patient was carried comatose to the hospital. 
The coma subsided in the course of a few hours, to leave a complete 
right- sided hemiplegia, which entirely disappeared in three days, 
leaving the individual in better physical and mental condition than 
for ten years. Many of the cases of so-called ' - serous " apoplexy 
characterized by sudden onset, and more especially by speedy re- 
covery, are really cases of pachymeningitis. 



702 MENINGITIS, SIMPLE CEREBRAL. 

The predominance of symptoms indicating cortical lesion is 
another feature of diagnostic importance. Thus localized convulsions 
and contractions, monoplegias, contracted pupils, following an apo- 
plectic attack in an individual predisposed to the disease by the fac- 
tors already emphasized, point almost certainly to pachymeningitis. 

The age and sex of the patient must not be overlooked. 

Basilar meningitis is differentiated by the youth of the patient, 
the family history, the presence of tuberculosis elsewhere, by its long 
prodromes, its insidious approach, its general and special hyper- 
esthesia, opisthotonos, boat-shaped abdomen, etc. 

Cerebro spinal meningitis prefers winter, soldiers, and children, 
occurs at times in endemic proportions, shows opisthotonos, herpes, 
and sometimes petechias, extreme hyperesthesia, spinal lesions, and 
does not recur. 

The prognosis is always grave. Recovery without recurrence is 
possible, but not probable. The patient succumbs, as a rule, in a 
subsequent attack, if he does not fall a victim in the meantime to the 
original disease. The immediate prognosis is best established, as 
after any cerebral haemorrhage, by frequent observations of the 
temperature, whereby the degree of the rise after the initial depres- 
sion incident to the shock would receive proper interpretation. A 
sudden or gradual elevation to a high grade (105°) at anytime there- 
after, independent of the original disease, is a sign of most ominous 
significance. 

Treatment. — The treatment of pachymeningitis does not differ 
materially from that of any form of meningitis or cerebral haemor- 
rhage. The application of an ice bag to the head, the local abstrac- 
tion ,pf blood by leeches or cups behind the ears or over the temples, 
"derivation" by purgatives (calomel, senna, croton oil), constitute 
the routine plan, which is sanctioned more by time and use than by 
benefit based upon demonstrable proof. Tranquillity of surround- 
ings, with all the measures which make up a more or less perfect 
hygiene, are the most effective agents in prophylaxis in the chronic 
psychoses; while abstention from alcohol addresses the "causa indi- 
cations " in cases dependent upon its abuse. B right's disease, heart 
disease, pernicious anaemia, etc. — in short, the underlying condition 
calls for appropriate treatment, and paralyses, convulsive manifes- 
tations, persistent headaches, whatever symptoms may be left, are 
to be met with symptomatic treatment. 

Pachymeningitis cervicalis hypertrophica is a peculiar 
subvariety of meningitis, produced by great thickening of the menin- 
ges in the cervical cord, and marked by severe pains in the back of 
the neck and both arms, with atrophy of the muscles of the neck and 
flexors of the hands, and final spastic paraparesis. 



LEPTOMENINGITIS. 703 



LEPTOMENINGITIS. 



It is possible, as already stated, that a real inflammation may 
limit itself to the dura mater alone, but such a distinct circumscrip- 
tion is very rare. Inflammation of the dura extends, as a rule, 
to involve the pia mater. The same qualification applies to the 
pia mater, though a strict limitation to the pia mater is more fre- 
quently observed. The subsequent remarks apply more especially 
to inflammation of the pia mater, with which the dura is, or may be, 
secondarily affected in greater or less degree. It is taken for granted 
that cerebro-spinal meningitis and tubercular meningitis, diseases 
due to special causes, are not included under the title leptomenin- 
gitis, which embraces all other kinds of simple meningitis of known 
or unknown cause. 

Leptomeningitis is always a secondary affection. The cases con- 
sidered idiopathic become, under closer observation, so much fewer 
every year that it is more safe to appeal to unknown primary affec- 
tions than to subscribe to the possibility of a spontaneous or idio- 
pathic meningitis of any kind. A thorough conviction in this regard 
will alone lead to the searching investigation necessary in man}' cases 
to discover the original disease. 

Affections of the ear constitute by far the most fruitful cause of 
leptomeningitis. Of these affections, chronic suppurative inflamma- 
tions of the tympanic cavity, which constitute over twenty per cent 
of all diseases of the ear, most frequently lead to meningitis through 
caries of the osseous roof of the tympanum. The roof of the tym- 
panum is composed of an excessively thin plate of bone, which is 
indeed at times congenitally defective, so that the way lies open to 
invasion of the cranial contents. 

A more or less open avenue is also offered in the course of, or 
along the sheaths of, the facial and auditory nerves and the vessels 
which penetrate the petrosal fissure. Communication by caries may 
be also directly established between the cavity of the cranium and the 
mastoid cells ; while indirect involvement of the meninges may fol- 
low phlebitis and thrombosis of the cavernous, transverse, and supe- 
rior petrosal sinuses, as revealed by dilatation of the veins and local 
oedema in the region of the mastoid process. Tuberculosis plays a 
prominent role as a special cause in the production of all these pro- 
cesses, while syphilis furnishes a small contingent of cases through 
caries of the upper meatus of the nose. 

Every meningitis whose cause is not obvious should excite sus- 
picion of ear disease, which may reveal itself to the sense of smell in an 
offensive odor, before or in the absence of visible discharge. So, also, 
every case of otorrhcea should excite the fear of possible meningitis. 



704 LEPTOMENINGITIS. 

Trauma or injury to the cranial bones constitutes a not infre- 
quent cause of simple meningitis. Where compound fracture has 
occurred, or direct penetration has been effected, the sequence is suf- 
ficiently simple. In other cases the meninges, though not directly 
exposed, become affected through phlebitis, thrombosis, or suppura- 
tions occurring in the patulous veins of the diploe, whereby is im- 
plied, as previously intimated, some hidden crevice or pre-existent 
communication with the air. A far more infrequent involvement of 
the meninges occurs at times, when an abscess in the interior of the 
brain reaches its periphery, or bursts into a lateral ventricle to come 
in contact with inflections of the pia mater at the base of the brain. 
So-called brain " softenings," which consist simply of brain and tis- 
sue debris, and simple hyperemias, the so-called "congestions" of 
the brain, including sunstroke, could not, with our present knowl- 
edge of the nature of infections, produce a leptomeningitis. 

Next in frequency to the direct invasion of the meninges from 
disease of the ear are the metastatic processes from distant depots of 
infection. Any one of the acute infectious diseases may be thus 
attended or followed by meningitis, which is justly regarded as the 
most serious complication which can occur — which, indeed, imparts 
a sudden gravity to an otherwise mild case of disease. Of all the 
acute infections, pneumonia is the disease in which this complication 
most frequently occurs. The intimate relations of tuberculosis of 
the lung and brain in the frequent sequence of basilar meningitis 
upon tuberculosis pulmonum, prepare us in a measure for the fre- 
quent supervention of meningitis in the course of croupous pneu- 
monia. The same connection or relation has been observed also in 
cerebro- spinal meningitis, and bacteriologists have pointed out the 
striking resemblance of the micro-organisms found in these two af- 
fections. Pyemia and septicemia may be said to vie with pneumo- 
nia in the production of metastatic meningitis, while endocarditis, 
empyema, acute articular rheumatism, the exanthematous diseases 
— more especially variola and scarlet fever (aside from ear disease), 
and very rarely typhoid fever — diseases mentioned in the order of 
frequency, furnish exceptional cases. As curiosities, equally illus- 
trative, however, of the nature of the process, may be mentioned the 
cases of meningitis which have followed such trivial infections as 
vaccinia and mumps. 

The morbid anatomy and symptomatology of this form of 
meningitis do not differ, except in the preference of the convexity to 
the base in the case of inflammation from metastatic and traumatic 
causes, from the cerebral signs and lesions of cerebro-spinal menin- 
gitis, which have been fully described elsewhere. 

The diagnosis of meningitis in connection with disease of the 



LEPTOMENINGITIS. 705 

ear, or trauma of the bones of the cranium, is very easy, as a rule> 
but the diagnosis of metastatic meningitis is often very difficult. 
High fever and blood poisoning show symptoms which so closely 
simulate the signs of meningitis as to render an absolute diagnosis 
impossible, at least for a time. The persistence of these signs after 
subsidence of hyperpyrexia sometimes declares the disease. Tuber- 
culosis, pyaemia, scarlatina, variola, erysipelas, and typhoid fever 
are the affections which oftenest create doubts as to the diagnosis. 
But if close scrutiny be made of the etiological factors, and close at- 
tention be paid to the course of the disease, the diagnosis, as a rule, 
soon becomes clear. In distinction from tuberculosis and typhoid 
fever, it may be said that meningitis develops quickly, almost sud- 
denly, with violent pain in the head, active delirium, and often with 
stiffness of the muscles of the neck or retraction of the head. 

Tuberculosis and typhoid fever show also typical temperature 
curves, with lung symptoms in tuberculosis, and abdominal symp- 
toms in typhoid fever. In scarlatina, variola, and erysipelas it is 
rather a question of detecting a complication, as each disease shows 
characteristic eruptions upon the surface. Here, too, the persistence 
of cerebral signs after subsidence of the high temperature is of 
value. Septic and pysemic diseases follow wounds, are attended 
with chills, show joint affections and internal metastases. Ulce- 
rative endocarditis, a septic process, has the same history. Uraemia 
is recognized by the dropsy, the condition of the urine, and, so far as 
the nervous symptoms are concerned, by the predominance of con- 
vulsions. 

Cerebro- spinal meningitis is differentiated by the more prominent 
disturbances of sensation, by herpes, and by the occurrence of other 
cases. Basilar meningitis occurs more especially in children affected 
with tuberculosis elsewhere, ^or who come of tuberculous stock. It 
has long prodromata and a longer, duration. Its symptoms are less 
acute and intense. It more frequently implicates the membranes of 
the spinal cord. Pachymeningitis is a disease of age. It occurs in 
drunkards, dementia paralytica, chronic insanity, etc. It shows a 
more fluctuating course. It must be repeated again and again that 
the various forms of meningitis are to be separated and recognized 
more by the etiological relations of the disease than by any dif- 
ference in symptomatology. 

The prognosis is far more grave than that of cerebro-spinal, but 
not so absolutely fatal as that of basilar, meningitis. The great ma- 
jority of cases terminate fatally, in coma or convulsions, in the 
course of from two to ten days. 

The treatment of leptomeningitis does not differ in any way 
from that of any other form of meningitis ; what little may be 
45 



706 LEPTOMENINGITIS. 

accomplished in the relief of symptoms has been mentioned under the 
title Cerebro-spinal Meningitis. The physician who is thoroughly 
indoctrinated as to the dangers of disease of the ear, and who is 
thoroughly familiar with the recent researches regarding the nature 
of infection, will prevent many cases of meningitis by timely treat- 
ment of the ear and by scrupulous antisepsis in all wounds of the 
skull. 



CHAPTEE XII. 

DISEASES OF THE SPINAL CORD. 
MYELITIS. 

Myelitis (ptveXo?, marrow). — Inflammation of the spinal cord, at- 
tended by paraplegia with anaesthesia, interference with the action 
of the bladder and bowels in the chronic form, and degeneration of 
the affected nerve cells, fibres, and muscles. The disease is distin- 
guished, according to its distribution, as central, transverse, peri- 
pheral, focal, and disseminate. Central myelitis, which affects 
chiefly the gray matter, is known as poliomyelitis (no'Xios, gray). 
Transverse myelitis affects a whole section ; peripheral myelitis, the 
outer layer ; focal is a local depot ; disseminate are scattered depots 
throughout the cord. 

History. — Inflammation of the cord was separated from that of 
its membranes at the beginning of the present century. It was at 
this time that the term myelitis was appropriately substituted for 
spinitis. The first extensive description was furnished by D'Angers 
(1821). Hereupon ensued the discussion as to whether or not the 
softening observed in the cord was of an inflammatory nature. Vir- 
chow decided this question affirmatively. The modern studies of the 
histology of the cord and of its physiology, as determined by ex- 
periments, furnish the data for 'the localizations effected in recent 
times. 

The etiology of myelitis remains obscure. Individual cases cer- 
tainly ensue upon exposure to cold, but experiments in this direction 
furnish contradictory results. The same statement may be made 
regarding the action of other causes — fatigue ; excesses, especially 
sexual excesses ; suppression of menses or other discharges, as from 
haemorrhoids, fistula ; sweating, as of the feet. 

The development of cases under the influence of mental emotions 
— anger, fright, etc. — is an assumption difficult of demonstration. 
The tendency of the present time is to ascribe all cases to the action 
of some toxic agent developed in the course of an infection and pos- 
sibly latent for some length of time. The affection of the cord which 
occurs in cerebro-spinal meningitis, and which may occur in septic 



708 MYELITIS. 

(puerperal) affections, small-pox, typhoid fever, etc., lends support 
to this view. Certain chronic cases are attributed to the influence 
of alcohol and syphilis. The disease has certainly followed after 
haemorrhage in the cord, and has occurred in consequence of all 
kinds of injuries ; hence myelitis is more common in males, and in 
the younger — that is, the more exposed — periods of life. The mye- 
litis of childhood is the affection, localized in the anterior cornua, 
which constitutes infantile paralysis. 

Morbid Anatomy. — Myelitis is divided into stages of hypersemia^ 
fatty degeneration, and cicatrization. In the stage of hyperemia 
the cord is swollen, reddened, and softened ; the vessels are sur- 
rounded with corpuscles and a gelatinous exudation. Nuclei multi- 
ply in the cells of the neuroglia. The axis cylinder in the nerve 
fibres is swollen, beaded, and granular. Ganglion cells are enlarged, 
apparently softened, separated, and robbed of their nerve fibres. 
In the second stage fatty degeneration brings about the yellow and 
white softening visible to the naked eye. A granulo-fatty degene- 
ration affects the vessels of the connective tissue and nerve elements 
in every direction. In the third stage the cord begins to shrink, its 
consistence increases, and fat accumulates in its tissues and cavities. 
The connective tissue proliferates, shows abundant spider cells and 
corpora amylacea. 

Symptoms. — The mode of onset is various. Sometimes symp- 
toms of iveakness set in at once, or the weakness may be preceded 
by pains or parcesthesice for several days. Convulsive movements 
are not so common. After the first feeling of weakness paralysis 
develops rapidly ; the patient soon finds himself unable to walk or 
stand ; rest does not relieve him. Control of the legs is lost, and the 
patient is put to bed, sometimes in the course of a few hours, para- 
lyzed in his lower extremities. The disease sometimes sets in in the 
night, so that the patient, who goes to bed apparently well, is unable 
to get up in the morning. There is also loss of sensation ; it is, 
however, not so complete and does not show itself so soon. The re- 
flexes may be increased or diminished, according as the seat of the 
disease interrupts the course of the nerve fibres or breaks up the 
centre itself. The bladder is affected at first with paralysis of the 
detrusor, later of the sphincter. There is, therefore, first retention 
and afterward incontinence from overflow. The bowels are af- 
fected in the same way. There is at first obstruction, but later 
paralysis of the rectum. Trophic changes assume prominence. It 
is almost impossible to avoid the production of bed sores of gan- 
grenous character. The slightest pressure causes destructive change, 
which shows itself usually first in the formation of blebs or bullae 
with bloody contents. The blister breaks to leave a slough ; some- 



MYELITIS. 709 

times the slough forms without pressure. The same trophic changes 
favor the development of cystitis from retention. Ulcers may form 
in the bladder, or cellulitis may develop in the perineum or lower 
abdomen. Myelitis usually begins below and extends upward, pro- 
gressively or interruptedly. More rarely it begins above in the cer- 
vical or dorsal region and descends to the lumbar region. 

The onset of the disease is usually attended with elevation of 
temperature to 102° to 104°. The temperature then subsides to the 
normal, and usually falls below normal in the paralyzed members. 
Complications, cystitis, septicaemia from bed sores, marasmus, may 
subsequently develop fever. 

Variation from these symptoms is shown in the more diffuse or 
disseminated forms of the disease. Thus a diffused myelitis is 
distinguished by the rapidity of its spread and the intensity of its 
symptoms. The disease may seem to show itself in both extremities 
simultaneously. Trophic disturbance is also more extensive, and 
death may ensue in the course of a few days. In disseminated mye- 
litis symptoms develop from different centres ; individual muscles or 
groups of muscles may be affected in one arm and the leg of the 
same or opposite side. Irregular distribution should alivays ex- 
cite suspicion of syphilitic origin. 

The prognosis must be made with caution. Cases which pro- 
gress rapidly often terminate fatally by involvement of the respira- 
tory centre. As a rule the disease comes to a stand in the course of 
a week, and the patient recovers with more or less paralysis, which 
may or may not yield to subsequent treatment. Any neglect in the 
management of a case may be attended by cystitis or sepsis. 

Treatment. — During the acute stage the inflammation is best 
treated by application of cold, in the form of ice bags, along the 
spine. Absolute rest, with attention to the secretions, is a sine 
qua non. The salicylates may be given at the start. 

Chronic Myelitis differs from the acute only in the more pro- 
tracted onset and development of the symptoms. Like the acute, it 
may be localized or diffused. The disease rests largely on a clinical 
basis, and is hence often confounded with the degenerations or 
scleroses. The transverse myelitis, where the thickness of the cord 
is involved at a definite region, presents the most typical form. The 
disease occurs more frequently in adolescence and maturity ; is un- 
known in infancy, and is very rare in age. 

Etiology. — With the exception of the cases that may be ac- 
counted for by a direct injury, or exposure to cold, especially during 
fatigue or after over-exertion, the etiology of the disease is obscure. 
From the fact that alcohol produces a peculiar affection of the peri- 
pheral nerves, which affects nerve tissue as in myelitis, certain cases 



710 MYELITIS. 

may be attributed to this cause. Gout is invoked as a cause in the 
old country. Syphilis has more to support it. 

Morbid Anatomy. — The cord may present no visible change to 
inspection, though some difference in color and consistence is often 
observed at the affected regions. The color becomes more gray or 
yellow and the consistence more hard. Changes are distinctly mani- 
fest under the microscope. There is alteration of the neuroglia, 
which becomes amorphous and fibrillated. Nerve fibres waste, the 
axis cylinder is beaded and narrowed, and the myeline takes on a 
deeper stain. The blood vessels are varicose ; granules accumulate 
with corpora amylacea. Nerve fibres, cells, and ganglionic masses 
waste and disappear. 

The symptoms set in very slowly, but vary little, notwithstanding 
the different localization of the disease. The affection is usually an- 
nounced by disturbance of sensation. Various parcesthesice come 
and go ; there are numbness and formication; the legs go to sleep; a 
girdle sensation is felt at the level of the lesion. Disturbance in the 
motor function is soon established. The slightest exertion produces 
fatigue ; the legs feel weak and heavy ; the bladder and bowels are 
early affected ; there is constipation, and the action of the bladder 
is slow. Impotence is soon established. Except in the cases where 
the centres are affected in the cord, the reflexes are increased. As 
the disease progresses, evidences of irritation — twitchings and con- 
tractions — disappear, and paralysis advances continuously. Muscles 
waste ; there is paraplegia. Two features distinguish the disease : 
first, the slow onset and gradual development, and, second, the pre- 
dominance of motor signs ; the motor system is affected so much 
more than the sensory. In both cases the direction is toward de- 
struction. The evidence of iveakness exceeds that of irritation. 
The anomalies of sensation are in the direction of anaesthesia. The 
disease lasts for years, and terminates life usually by complications, 
especially by decubitus and cystitis. Recovery is possible, but ex- 
ceptional ; hence the prognosis is bad. 

Treatment. — With the exception of the few cases which may be 
due to syphilis, there is no radical address in therapy. Antisyphi- 
litic treatment, if pushed too far, aggravates the disease. Iodide of 
mercury, in minute doses, gr. ■jg-gV? is the best form. Arsenic is 
often an admirable tonic. Phosphorus, silver, strychnia, are reme- 
dies that may be tried, with but little hope of benefit. More is to be 
accomplished by hygiene. Warm baths are of value always. Hot 
peat and mud baths sometimes do good. Counter-irritation, as by 
stripes with the actual cautery, on each side of the spine, at the seat 
of the disease, sometimes produces remarkable results. The strokes 
may be repeated at intervals. Absolute rest is of great advantage at 



LOCOMOTOR ATAXIA. 711 

first, but, maintained too long, favors degenerative change. Galvan- 
ism, with short sessions and gentle currents, may arrest the advance 
of the disease. Faradization may support the muscles for a time. 
Constant attention must be paid to the bladder and the bowels, and 
especially to the prevention of bed sores. 

LOCOMOTOR ATAXIA. 

Locomotor ataxia (a, without, ragis, order). — The most frequent 
and one of the most grave affections of the spinal cord, caused by 
sclerosis of its posterior columns ; characterized by peculiar pains and 
parsesthesiae, diminution and loss of the reflexes, disturbance of 
vision, impotence, inco-ordination of muscles, especially of the lower 
extremities, and very slowly progressive paralysis. 

History. — The term tabes dorsal is, wasting of the back, was used 
by Hippocrates to express certain symptoms attributed to venereal 
excess, and was limited to this tabes by Romberg (1851), who first 
distinctly isolated the affection with a classical description in his text 
book on nervous diseases. Duchenne (1858) named the disease pro- 
gressive locomotor ataxia. The main clinical symptom, the lack of 
co-ordination of muscles with retention of voluntary power, was actu- 
ally first recognized and differentiated from ordinary paralysis or 
paraplegia by the English physiologist, Todd (1847), who is the real 
pioneer in this disease. From the seat and character of its lesion it 
has been named posterior spinal sclerosis. Though Todd had, from 
the nature of its symptoms, located the disease in the posterior col- 
umns of the spinal cord, it was reserved for Rokitansky (1856) to 
demonstrate and define the lesion as a chronic, diffuse inflammatory 
process, which converted the portion of the cord affected into a mass 
of indurated connective tissue. During the following decade French 
observers, more especially Charcot, Vulpian, Luys, connected the 
various complex symptoms with the functions of the cord, and Fried- 
reich separated the hereditary form. A most important contribution 
was made by Westphal (1878) with the discovery of an early and 
almost pathognomonic symptom in the loss or absence of the knee 
jerk. Charcot and Raynaud observed the various crises, gastric, 
laryngeal, and nephritic crises, alterations of bone, etc. 

Etiology. — The disease occurs more frequently in males than 
females, in the proportion of ten to one, and ranges close about the 
middle period of life. One -half of the cases occur between thirty 
and forty, one-fourth between forty and fifty, and less than one- 
fourth between twenty and thirty; it begins but rarely after fifty, 
and still more rarely under twenty. Any influence of heredity can 
be traced only very exceptionally — in fact, in but ten per cent of 
cases. 



712 



LOCOMOTOR ATAXIA. 



Syphilis is the overshadowing cause. Statistics of different 
authors vary as to the frequency of this cause. Fournier puts it 
as high as 75 per cent. The disease usually occurs in the remoter 
course of syphilis, and is rare in the early history of the disease. It 
may follow any of the acute infections, especially diphtheria, and has 
been attributed to excesses, especially sexual excess, and, with all ob- 
scure maladies, in the absence of other cause, to taking cold. 

Morbid Anatomy. — The disease is distinguished by sclerosis and 
atrophy of the posterior columns of the spinal cord, which assume 
a grayish-yellow color, and show the granulo-fatty changes, with 
hyperplasia of the connective tissue, characteristic of this degenera- 
tion. The dorsal and lumbar portions 
of the cord are most affected. At these 
portions the membranes are usually 
found adherent. In the cervical region 
the degeneration is usually found lim- 
ited to the columns of Goll. In the 
dorsal region it affects all parts of the 
posterior columns, while in the lumbar 
region the anterior portion of the pos- 
terior columns remains usually unaf- 
fected. The degenerative process gen- 
erally stops at the level of the stria3 
acoustics. Certain cerebral nerves, 
the trunk of the optic, the nerves which 
innervate the ocular muscles, espe- 
cially the oculo-motor, are picked upon 
by preference. Both halves of the 
cord suffer alike; the process is always 
symmetrical, and is usually strictly so. 
The degeneration of nerve tissue pre- 
cedes the hyperplasia of the connec- 
tive tissue. The process is a pure degeneration and is in no sense an 
inflammation. 

Symptoms. — The symptoms of locomotor ataxia fall naturally 
into three groups, the sensory, atactic, and paralytic, which pre- 
sent themselves in predominance in succeeding stages of the disease. 
But these symptoms show no necessary sequence; they may occur at 
any period of the disease. Individual cases begin with atactic symp- 
toms, and sensory phenomena show themselves throughout the whole 
history of the disease. Paralyses are commonly limited to the last 
stage. Locomotor ataxia is usually announced by peculiar pains, 
which are distinguished by their suddenness of occurrence, inten- 
sity, and shortness of duration. Lancinating pains, like lightning 




Fig. 280.— Beginning sclerotic patches, 
a,a, in the posterior columns of the cord. 



LOCOMOTOR ATAXIA. 713 

strokes, shoot through the body, the pelvis, and lower extremities, 
more rarely the upper extremities. The attacks of pain usually occur 
in paroxysms of one or several days' duration, with subsequent inter- 
vals of days, weeks, or months. Sometimes the pains are more or 
less constant; in very rare cases they may be entirely absent. An 
equally early symptom is some anomaly of sensation, especially in 
the lower extremities. The anomaly may be appreciated first as a 
diminished sensitiveness to the faradic current. The surface may 
become almost insensitive to severe, but abnormally sensitive to 
slight, irritation. Thus the touch of a pin may be experienced as 
pain, while penetration through the skin is scarcely felt at all. The 
perception of pain may be also very much delayed. 

Paro3sthesio3 are much more common. Sensations or anomalies 
of sensation in the soles of the feet are very frequent. Patients speak 
of walking on cushions, on wool, on ovals, girdle sensations, etc. 
The paresthesia is usually in the direction of an anaesthesia, and the 
loss of sensitiveness concerns also the deeper tissues as well as the 
skin. So a disease of an internal organ may give rise to no distress; 
a pleurisy may be painless. 

The loss of the poiver of co-ordination constitutes a symptom 
so striking as to have given the name to the disease. It shows itself 
first in the legs, and gives to the patient a characteristic gait. The 
regulation of nerve force to muscular contraction is so nicely ad- 
justed as to be unconscious and automatic. In locomotor ataxia the 
course of the impressions through the cord to the brain is broken into 
and interrupted, so that the patient must aid his estimate of effort 
with the sight. Many of these patients stumble and fall on rais- 
ing their eyes from the ground at their feet. So, too, the legs are 
lifted with unnecessary force, and the feet are planted flat in a kind 
of mechanical way. To broaden the base of support, the patient 
must stand with the feet more widely separated, and in the further 
course of the disease he must invoke the aid of a cane that he may 
get the firmer support of a tripod. So the diagnosis of locomotor 
ataxia may often be made upon the streets. 

All the symptoms of inco- ordination become much more mani- 
fest when the patient withdraws his sight, and one of the early signs 
of the disease is the inability to stand still with the eyes closed; 
in all cases swaying is much increased, and in marked cases the pa- 
tient, unless supported, would fall. The ability or inability to stand 
upon one foot or walk backward, or make special motions with the 
foot while the leg is supported by the hand in the sitting posture, are 
signs of value, but of less value. In the course of time the inco- or- 
dination affects also the upper extremities. It is noticed, of course, 
in the finer movements first. The deftness and dexterity of the hand 






714 



LOCOMOTOR ATAXIA. 



are lost. This loss is observed more especially in the automatic 
movements of the trades, in writing, piano playing, in dressing and 
undressing, especially in buttoning and unbuttoning garments. 

The single symptom of supreme value is the diminution or loss of 
reflex, as manifest more especially in the absence of the patellar reflex, 
"loss of knee jerk." The patellar reflex is first diminished and, 
then lost. In the earlier history of the disease this diminution and 
loss is more marked on one side than the other. Total loss of knee 
jerk in a patient affected with a nervous disease should always sug- 
gest locomotor ataxia first. The symptom is universally present, and 
is best elicited by a stroke upon the patellar tendon as the patient 
sits upon a table with the legs hanging over the side. In people of 
ordinary build it is sufficiently distinctly brought out in the sitting 

posture with the legs crossed, and in 
patients in bed it may be estimated 
by support of the thigh with the left 
hand while the right is used to give 
the blow. What reflex there is may 
be always reinforced by simultaneous 
use of other muscles, as by a firm 
grasp of the hand, tight closure of 
the eyes, etc. The ankle clonus is 
diminished and lost in the same way. 
The skin reflexes suffer likewise, so 
that in an advanced case even tick- 
ling of the foot may provoke no with- 
drawal of the leg. In this connection 
may be mentioned also the loss of sexual power, which may even 
precede for months the atactic signs. In exceptional cases the sexual 
power may be preserved up to the period when the patient may no 
longer walk alone. 

Symptoms on the part of the eye occur in the large proportion of 
cases. The reflex of the iris is lost in five- sixths of all cases, while at 
the same time the power of accommodation remains. This loss of 
response to light, with preservation of accommodation, first dis- 
covered by Argyll-Robertson and commonly known by his name, is 
a characteristic sign of the disease. Irritation of the skin at the back 
of the neck no longer produces dilatation of the pupils. In these 
cases of loss of reflex dilatation the pupils • are commonly contracted, 
and "pinhead" pupils (spinal myosis) should suggest locomotor 
ataxia. It is needless to state that this condition is not necessary. 
The pupils are sometimes dilated, more frequently normal. The eye 
muscles are affected in every degree, from slight transitory paresis 
to total palsy. Atrophy of the optic nerve is the most distressing 




Fig. 281.— Knee jerk after tap on patellar 
tendon; dotted line represents response. 



LOCOMOTOR ATAXIA. 



715 



complication of locomotor ataxia. It sometimes begins very early in 
the history of the disease, and may itself suffice, without the exist- 
ence of other signs, to foretell the disease. The atrophy is at first 
peripheral, but with the slow progress of the disease may become 
total. The only consolation connected with these apparently uncon- 
solable cases is the evident arrest of the progress of the disease in 
the cord; for, in the presence of optic atrophy, the degenerative pro- 
cess in the cord is usually brought to a standstill. The other cere- 
bral nerves are rarely affected in this disease. 

The mind remains unaffected and becomes quickly resigned to 
the ravages of the disease. A kind of jocund indifference has been 
remarked of most cases. The vegetative functions are usually nor- 
mal, the appetite is good, the bowels are sluggish and must often be 
aided by cathartics and injections. Sooner or later the bladder be- 




Fio. 282.— Tabes ; perforating ulcer of the foot (Gowers). 



comes involved, at first the detrusor, later the sphincter, so that in- 
continence or retention of urine may occur. Close attention must be 
paid to the bladder in these cases to prevent overdistension and 
cystitis. Atrophic changes, especially eczematous eruptions in the 
skin ; softening of bones and alterations of joints ; excruciating, 
paroxysmal pains in the internal organs, larynx, stomach, kidneys^ 
etc.; so-called " crises"; perforating ulcers, especially of the feet,, 
are more uncommon signs. 

Locomotor ataxia is a disease of long duration, often of many 
years, and, though it may undergo arrest at various stages of the 
disease, it remains entitled to the term progressive given to it with 
its name. Recovery occurs only in the most exceptional cases. 

In pronounced forms the diagnosis is easy. The lancinating 
pains, loss of the knee jerk, immobility of the pupils, are the cardinal 
signs. The reduction of sensibility, especially of deep sensibility, the 
various pargesthesise, the amblyopia and amaurosis, the affections of 



716 HEREDITARY ATAXIA. 

the bladder, impotence, and ataxia, with at first preservation of 
power, unmistakably stamp the character of the disease. 

Treatment, so far as cure is concerned, offers but little promise, 
but treatment may alleviate the symptoms and possibly arrest the 
progress of the disease. As locomotor ataxia is a sequel to, rather 
than an effect of, syphilis, antisyphilitic treatment has over it little 
or no control. Nevertheless the treatment should be faithfully tried. 
Mercury should be administered by inunction, and iodine should be 
pushed to tolerance. The hope in this connection lies in a longer 
treatment of the syphilis itself, whereby the poisons it leaves may be 
in the course of time thoroughly destroyed. The patient should be 
protected against cold and fatigue; attention is to be paid to the diet 
and digestion. Excess of any kind, especially sexual excess, must 
be avoided. Warm baths are of great value. Of the host of drugs 
recommended arsenic is the best, and Fowler's solution is the best 
form of it. Many cases improve under it rapidly for a time. It 
should be given in small doses, gtt. ij.-v., over a long time. Pains 
may be controlled by phenacetin gr. v.-x. Quick relief is sometimes 
obtained by the application of excessively hot water, or better by the 
injection of cocaine gr. J subcutaneously at the site of pain. Severe 
pains are controlled only by morphia subcutaneously. Visceral pains 
may be addressed in the same way. Laryngeal spasms may be re- 
lieved by the nitrite of amyl or nitroglycerin. Paresis of the bladder 
is best overcome by strychnia, which is best given subcutaneously in 
small commencing and progressively increasing, gr. j-g-o— A> doses. 
Impotence is often quickly relieved by extension — that is, by sus- 
pension — which has in nearly all cases good effects in every direction. 
Unfortunately, however, suspension in no way really controls or 
oures the disease. 

HEREDITARY ATAXIA. 

Hereditary ataxia {ataxia, disorder) was first described by 
Friedreich (1861). It is, as the name implies, transmitted by hered- 
ity, and shows itself in several members of the same family, though 
individual cases are sometimes observed. The lesion is in the poste- 
rior lateral columns, and the effect is observed in the legs in inco- 
ordination and frequent falling. The disease extends to involve the 
upper extremities, the trunk, finally the tongue. Pains are dull and 
localized. Sensation is not disturbed. The disease is distinguished 
from locomotor ataxia by the fact that it occurs in childhood, 
progresses even more slowly, and is unattended with shooting pains, 
affection of the bladder or of vision; it has no crises and no arthro- 
pathies. 



LATERAL SCLEROSIS. 



717 



LATERAL SCLEROSIS. 



Lateral sclerosis; spastic paraplegia; spastic spinal paralysis. — A 
degeneration of the pyramidal tracts, characterized by paresis or 
paralysis of the lower extremities, with spastic contraction of the 
affected muscles; exaggeration of the tendon reflexes with slight 
reduction of electric excitability; without affection of the bladder or 
bowels, and without trophic change. 

History. — This degeneration was first observed by Ttirck (1856), 
afterward by Charcot (1865), but was more distinctly isolated by Erb 
(1875). The disease may occur at any period of life, but is most 
common at from twenty to forty years of age, decades which include 
three-fourths of all the cases. Very exceptional 
cases may occur as early as infancy and as late 
as the age of sixty. 

Etiology. — The cause remains involved in 
obscurity. The congenital form is always due 
to injury of the brain in birth. Syphilis could 
be considered a cause as rarely as it is frequent 
in posterior sclerosis (locomotor ataxia). A cer- 
tain percentage of Gases could be attributed to 
trauma, fall, blow, or concussion, after which, 
with the lapse of a long interval, sometimes of 
several years, the disease has been known to de- 
velop. In the absence of other discoverable cause 
it has been ascribed to exposure to cold, to chro- 
nic rheumatism or other protracted or exhausting 
disease. The symptoms of spastic paralysis may 
show themselves in connection with the other 
symptoms of chronic hydrocephalus, transverse myelitis, multiple 
sclerosis, and other diseases of the brain and cord of more distinct 
anatomical lesion ; for the view that this spinal paralysis depends 
upon a sclerosis of the pyramidal tracts or lateral columns is rather 
an inference than a demonstration, as the cases reported to rest upon 
an anatomical basis by actual demonstration are not entirely free 
from objection. 

Symptoms. — The disease begins with iveakness of the legs, early 
fatigue, and unsteadiness, and progresses so slowly as to make itself 
distinctly manifest only in the course of several months. In many 
cases some kind of locomotion is preserved for years. The progres- 
sive paresis is unattended with atrophy, but is distinguished by an 
excessively heightened reflex excitability. A stroke upon the 
patellar tendon calls out powerful extension with subsequent convul- 
sive movements. Rectus clonus and foot clonus are also easily 




Fig. 283. — Scleroses on 
cross section of the lateral 
columns of the cord: a, b, 
c, sclerotic patches. 



718 LATERAL SCLEROSIS. 

excited. This excitability is manifest with every action of the muscle, 
and is noticed first as stiffness of the legs upon rising in the morning. 
It varies in every degree from slight muscular twitchings to tetanic 
rigidity, and is so constant as to be absent only in cases of complete 
flexion and relaxation. With the first attempt at extension the spas- 
modic condition renews itself at once, and so powerfully as often to 
spring the leg into a state of complete extension, the condition known 
as " clasp-knife " rigidity. In advanced cases the reflex shows itself 
also in sleep, when the legs may be suddenly jerked up in bed. 
The surface shows also more or less intensely heightened reflex. 
But with all this disturbance on the part of the motor system, the 
sensitive and secretory centres are unaffected, there is never the 
slightest ataxia, there is no impotence, no affection of the bladder 
or bowels, and no disturbance of the brain or organs of special sense. 
The development of any of these symptoms, or symptoms on the part 
of these organs in exceptional cases, belongs to complications. 

The gait is characteristic. The spastic contraction neutralizes 
the action of the joints and fixes the partially flexed leg as if by anky- 
losis. The patient steps upon his toes, and advances with a series 
of short hops, the whole body leaning forward, with a constant ten- 
dency to stumble and fall ; the legs are closely pressed together and 
are only separated with difficulty, as if being pulled apart in progres- 
sion. This habitus of the body in locomotion is so distinctive as to 
establish the nature of the disease at a glance. The upper extremi- 
ties remain, as a rule, unaffected, but may show in the course of 
years the same spastic contractions. The muscles of the trunk may 
also become involved, and a tap on the chin may evoke sudden 
closure of the lower jaw. When the disease occurs in infancy it is 
recognized in the same way, by the sudden extension of the leg, 
which may shoot out to a straight line as the child is seated upon the 
lap or a chair. 

Diagnosis. — This sclerosis is distinguished by gradual onset, a 
fact which at once eliminates cases in which symptoms suddenly 
develop; by the growing weakness, with spasmodic contractions and 
heightened reflexes, while at the same time the muscles do not waste 
and the bladder and bowels remain unaffected. The disease is dis- 
tinguished from the paraplegia of hysteria, aside from considerations 
of history, age, and sex, by the remarkably strict confinement of the 
spasm to acts of extension ; the spasm ceases in relaxation. Rectus 
clonus and ankle clonus are almost unknown in hysteria. The dura- 
tion is indefinite. 

Prognosis. — The disease is persistent, yet it may not much cur- 
tail life. Recovery, which is the rule in infantile forms, may occur 
only in very exceptional cases in adult life. 



PROGRESSIVE MUSCULAR ATROPHY. 719 

Treatment. — Rest is the most valuable agent. Exercise should 
be rather passive than active ; riding is better than walking. Mas- 
sage, especially by upward rubbing, with warm baths, especially 
Turkish baths, are remedies of value. Recoveries have been re- 
ported under the long-continued, systematic use of massage, hot 
baths which excite sweating, and gentle exercise. The only drug 
worthy of mentioning in connection with the disease is arsenic, 
which at least aids digestion and supports nutrition. Electricity in 
any form is useless, if not injurious. The muscles are already over- 
stimulated . 

Ataxic Paraplegia is a combination of posterior and lateral 
sclerosis, which begins with the signs of lateral sclerosis — i. e. , with 
spastic excitability — and soon shows the ataxia but not the pains or 
loss of reflex of posterior sclerosis. Thus the knee jerk persists or is 
increased. The cause is probably a chronic toxaemia. Foundation 
for this view is furnished in the disease known as pellagra, an 
Italian endemic, which shows symptoms of ataxic paraplegia, is 
attended by degeneration of the posterior and chiefly of the lateral 
columns of the cord, and is clearly caused by a toxine ingested with 
diseased maize. Ataxic paraplegia is not caused by syphilis. The 
prognosis and treatment are the same as for lateral sclerosis. 

PROGRESSIVE MUSCULAR ATROPHY. 

Wasting palsy ; amyotrophic lateral sclerosis. — Characterized by 
atrophy of certain muscles without paralysis, or with but that de- 
gree of paralysis which corresponds to loss of substance, with fibrillar 
twitchings, with the reaction of degeneration, with reduction of the 
reflexes, with preservation of sensation, and normal action of the 
bladder and bowels. 

History. — Hippocrates noticed this atrophy, but Van Swieten 
was the first to separate it from simple emaciation. Bell (1830) dis- 
tinguished it from a paralysis. Cruveilhier considered it a spinal 
disease. Aran (1850), who first named it progressive muscular atro- 
phy, located the disease in the muscles, as did also later Duchenne 
(1849), and still later Friedreich (1873). Lockhard Clarke (1862) 
located the disease in the spinal cord, and Charcot (1874) distin- 
guished it as an atrophy of ganglion cells and thus definitely deter- 
mined the lesion of the disease. 

Etiology. — An important role is played by heredity ; the disease 
is sometimes transmitted through many generations. It may occur 
occasionally at any period of life, but is most frequent between thirty 
and fifty years of age. Cases have been recorded of inception at 
twelve and seventy, but such cases must be regarded with suspicion, 
as age secures almost absolute exemption. Men are affected more 



720 PROGRESSIVE MUSCULAR ATROPHY. 

frequently than women, in the proportion of five to one. But thirty- 
three of the one hundred and seventy-six cases collected by Fried- 
reich were females — a disproportion evidently due to the greater use 
of the muscles in men. The working class, especially hand workers, 
furnish the majority of cases. The influence of mental distress, 
sexual excess, syphilis, trauma, exposure to cold and wet, has been 
distinctly noticed in individual cases. The disease has followed in 
the course of typhoid fever and diphtheria, and has occurred more 
frequently in connection with, or as a consequence of, other organic 
neuroses, as bulbar paralysis, infantile paralysis, in the history of 
the individual, arrested since infancy. 

Symptoms. — The onset is insidious and imperceptible. The dis- 
ease begins in the muscles of the upper extremities, in the right 
oftener than in the left, and shows itself as a feeling of weakness, 
sometimes preceded by pains or sensations of coldness, with loss of 
substance. The weakness and wasting come and go together — that 
is, the weakness is due to the toasting. The disease is distin- 
guished by the particular muscles or group of muscles which it first 
selects. The weakness is first noticed in the shoulder, the wasting 
in the hand. The process begins in nine-tenths of cases either in the 
shoulder or in the hand, and is about equally frequent in each. Of 
the muscles of the hand the first attacked are the inter ossei and the 
muscles that constitute the ball of the thumb, the opponens and ad- 
ductor, muscles which constitute the thenar and hypothenar emi- 
nences. The wasting of these muscles impairs the power of the 
hand, at first for delicate movements (writing), later for all move- 
ments. At the shoulder the deltoid suffers first and most. The loss 
of substance flattens the shoulder and thins the hand, to make 
conspicuous the bony prominences of the acromion, and in the hand 
to make manifest first the ends and later the whole shaft of the 
metacarpal bones, which, with the grooves between them, present the 
appearance of a skeleton hand. In exceptional cases the disease may 
begin in other muscles of the arm or leg, if invited thereto by par- 
ticular strain. Wherever it begins, it gradually extends, generally 
centrifugally — thus, from the hand to the forearm, arm, and 
shoulder, and from the foot to the leg and thigh. The disease pro- 
gresses symmetrically, though not absolutely uniformly, as fibres and 
groups of normal tissue may always be seen in the midst of degene- 
rated masses. In all uncomplicated cases the muscles of the face 
and neck, the diaphragm, and rectus abdominis are the last, if at 
all, attacked. 

Where the muscles, of the back, especially of the back of the 
neck, are affected, as may sometimes happen first, the patient has 
difficulty in sustaining the head upon the vertebral column, and in 



PROGRESSIVE MUSCULAR ATROPHY. 721 

the effort must tip the head somewhat backward. So soon as the 
balance is lost the whole head falls forward, with the chin upon the 
chest, and is with difficulty restored. In advanced cases the muscle 
substance is completely wasted and seems to entirely disappear, to 
reveal distinctly the subjacent outlines of bones. Over all the af- 
fected muscles may be seen fibrillary tivitchings — slight contrac- 
tions which show themselves spontaneously, or, upon exposure of 
the surface, under the slightest irritation. They may be always 
called out by drawing the wet finger over the surface and blowing 
upon it. It is nothing in the nature of a contraction which moves 
the limb. Functional or spasmodic contractions are almost never 
seen. It is merely a superficial, flickering movement, and is of value 
in that it sometimes shows itself in muscles not yet, but about to be, 
involved in the disease. Though there is no loss of sensation, the 
reflex is lost with the advancing waste of muscle and loss of motion. 
The reaction of degeneration sets in very slowly and corresponds 
to the degree of destruction. Peculiar deformities are caused by 
the wasting of individual muscles or groups of muscles, while their 
antagonists are spared. The most characteristic of these changes is 
seen in the claw hand. Yaso-motor and trophic disturbances are 
frequent. The atrophied members are cold, often cyanotic, more 
rarely covered with sweat. The skin is often the seat of eruptions, 
and the bones and joints may show trophic change. 

Morbid Anatomy. — The disease consists, in essence, of a degene- 
ration of motor ganglia in the pyramidal tracts. The motor cells 
seem on inspection to have almost entirely disappeared ; sometimes 
not a single large cell may be seen. The affected muscles show the 
signs of fatty degeneration. The strise are separated, absent, or 
substituted by granules, and fat globules accumulate throughout the 
structure. The preservation of bundles of normal tissue in the 
midst of this ivaste is characteristic of the disease. 

In diagnosis the disease is to be separated from traumatic 
lesions of the ulnar nerve, which show the same deformity in the 
hand, but always, of course, in but one hand; from rheumatic affec- 
tion, which may show it in both, but would not involve other 
muscles in the order of frequency, and would be distinguished by 
the presence of pain. The slow development, order of progression,, 
and limitation to the motor system define the disease. 

The prognosis is bad. Arrest may occur, with recovery and 
restoration by hyperplasia of unaffected fibres ; but recovery is rare. 
The disease is, as its name indicates, progressive, and is in its later 
course usually complicated with bulbar paralysis with its necessa- 
rily fatal prognosis. 

Treatment. — The body is to be supported with food and fresh 

46 






722 INFANTILE PARALYSIS. 



air. Anxiety and fatigue must be avoided. Gentle massage is of 
value, as is also the use of electricity, which, in the mildest constant 
currents, sometimes suffices to arrest the disease. The only drug 
worthy of mention is strychnia, which should be used subcutane- 
ously in the form of the nitrate, in small doses at first, gr. T -^-, 
increased to gr. ¥ V, once a daj-. The dose must be kept down to 
avoid overstimulation, and every intervention must be mild, per- 
suasive, rather than forcible. 

INFANTILE PARALYSIS. 

Poliomyelitis (noXioS, gray) ; essential paralysis of childhood ; 
acute anterior poliomyelitis. — A rapid paralysis with atrophy, chiefly 
of one or both lower extremities, more rarely of an upper extremity 
or of one side of the body, with loss of the reflexes, but preservation 
of ihe action of the bladder and bowels ; with the reaction of de- 
generation ; with intact sensation ; sometimes with deformities from 
contractures of unaffected muscles. The disease, which is certainly 
an infection, may begin with fever or convulsions. 

History. — Heine (1840) wrote the first monograph in which the 
symptoms were associated to constitute a separate disease. Cornil 
(1863) first saw lesions in the spinal cord. Prevost and Vulpian 
(1865) located the lesion in the anterior cornua — a localization subse- 
quently confirmed by Lockhard Clarke (1868) and Charcot and Jof- 
froy (1870) as the true seat of the disease. Duchenne (1872) ob- 
served the affection also in adults. 

Etiology. — Age is the most important factor ; six-sevenths of 
cases occur within the first three years. The disease is rare before 
four months, but has been observed as early as the twelfth day. It 
is rare in after-childhood, and is very rare in adults. It is more fre- 
quent in summer than in winter, and has thus been attributed to 
cold, as after exposure at night in bed. It has been noticed to oc- 
cur in a few cases within a few days after exposure to cold, as from 
a draught, from sitting upon damp groun d, etc. Attacks after fatigue, 
trauma, and during dentition are probably coincidences. More close 
is the relation of the infections, which more distinctly liberate some 
toxic element to produce the disease. 

Morbid Anatomy. — The process is closely limited to the gray 
matter in the anterior cells, where it attacks and destroys the multi- 
polar ganglion cells. The cells lose their poles, shrivel, and are 
filled with pigment and granular matter. The disease may extend 
to involve the lateral columns. There is an increase in the connec- 
tive tissue, with strangulation and destruction of nerve elements. 
Whole bodies of cells seem to have disappeared or be substituted by 
corpora amylacea. The paralysis and wasting are to be directly 



INFANTILE PARALYSIS. 723 

attributed to the destruction of the multipolar ganglion cells in the 
anterior cornua. The process shows its main expression in the 
lumbar enlargement, next in the cervical, and last in the dorsal por- 
tions of the cord. It is not, as a rule, symmetrical. It is usually 
focal, but may be for a short distance funicular. 

Symptoms. — The disease begins as an infection, with toxic signs 
— i.e., with fever, headache, restlessness, sometimes with stupor, 
delirium, and convulsions. Individual cases are announced with 
anxiety and pain. Vomiting is common, sometimes with diarrhoea, 
so that the case may be interpreted as a mere gastro-intestinal ca- 
tarrh. These symptoms may be slight or pronounced. They may 
last for several days, and some time in the course of them the char- 
acteristic symptoms develop. It not infrequently happens that the 
child is put to bed indisposed or ill, and wakes up paralyzed. It is 
observed that the child has lost the power of motion from one or 
both legs. Sensation is unaffected. The jjaralysis develops rap- 
idly, but is always worse at first ; not infrequently the paralysis ex- 
tends from one to other members. There may be incontinence of 
urine from affection of the bladder. But the advance of the disease 
is soon checked. It is a characteristic of this spinal paralysis that 
it soon comes to a standstill and recedes to some extent. Power 
over the bladder is quickly regained ; the paralysis may disappear 
entirely in the course of a few weeks or months. As a rule, how - 
ever, the improvement is only partial, and enduring paralysis is left. 

The changes of atrophy now intervene. The wasting process 
is marked, the skin is cold and purple, the surface is often mottled, 
and all the reflexes are lost from disruption of the muscle reflex 
centre in the gray matter of the cord. The atrophy is more rapid 
than after section of the nerves, and is associated with the develop- 
ment of the reaction of degeneration. Development is arrested 
in all parts of the affected member. Bones cease to grow, in fact 
they actually diminish and show deformity in comparison with the 
sound limb, which continues in normal development. The varieties 
of talipes, with various scolioses, may form for life. Under all 
this wasting process the brain remains unaffected, and with the sub- 
sidence of the acute signs at the start all the functions of the body 
remain normal. In adults the symptoms of the onset are less pro- 
nounced and the distribution is more irregular. Sometimes the para- 
lysis is crossed, or one side of the body is affected, or nerves usually 
spared are involved ; thus the facial may be attacked, and char- 
acteristic changes show themselves in the face. In children the dis- 
ease affects the legs three times as often as the arms, the left leg 
twice as often as the right. Irregular distributions are more un- 
common. 



724 



INFANTILE PARALYSIS. 



Diagnosis. — The rapid paralysis and atrophy in close association 
distinguish the disease. It is especially to be remarked that the 
symptoms are always worse at the start; that afterward the disease 
subsides to some extent. The disease is non-progressive, though it 
finally leaves permanent lesions. In two-thirds of cases the lesion is 
confined to one member, and in even the worst cases there may be 
usually discovered fibres or bundles of unaffected, or but slightly 
affected, muscles. 

The association of paralysis and atrophy, both rapid in onset and 
^marked, often extreme, in degree, whether preceded or not by gene- 
ral signs, sufficiently distinguishes the disease. 

The prognosis is good so far as life [is concerned, but bad con- 
cerning recovery. The amount of lesion to be left may be deter- 





Fig. 284.— Posture of healthy child. 



Fig. 285.— Posture of infantile paralysis; 
supported by the arms. 



mined only after the subsidence of the acute signs at the onset. 
Muscles which at that time still respond to faradization will probably 
recover; muscles which fail to respond, or respond but very feebly, 
will recover in part or not at all. The degree of atrophy will deter- 
mine the prognosis later on. Loss of power after three months 
indicates destruction of nerve cells. Response to faradization at any 
time leaves possible a certain degree of recovery. 

The treatment of the first stage is wholly symptomatic. Warm 
baths, broken doses of Dover's powder, the salicylates, salicin or salol, 
may to some extent counteract the fever, the toxines, and their associ- 
ate signs. With the subsidence of the acute stage after the lapse of 
three or four weeks, treatment is directed to the paralysis with strych- 
nia and electricity. Strychnia should be given in small doses, one- 
one-hundredth of a grain, at first, and gradually increased but not 



BULBAR PARALYSIS. 725 

pushed, and by the mouth rather than subcutaneously. Electricity 
acts with more direct relief by support of the muscle. It should be 
used in the form of the galvanic current, and applied both to the 
spine and the muscle, negative pole at the spine. The central effect 
is best obtained by the application of electrodes above and at the 
level of the disease in the cord. The peripheral is applied best in the 
form of the labile current, with one sponge at the entrance of the 
nerves and the other stroked over the body of the muscle, the sponge 
being lifted from the skin with each stroke. The current should 
be feeble, that from but a few cells, at first, and gradually increased 
to many cells, as man}' as may be borne. Occasional reversal of the 
current assists in the process. The treatment requires great patience, 
but should be persisted in under the very slightest encouragement, as 
it offers the only hope of relief from deformity and restoration to use. 
Frictions, massage, and stimulating applications help to sustain the 
circulation. Cod-liver oil and phosphorus are indicated in debilitated, 
more especially in rachitic, cases. Orthopaedic devices may relieve 
deformities in helpless cases and enable the patient to get about, and 
thus sustain the general health. 

BULBAR PARALYSIS. 

Glosso-labio-laryngeal parahysis (Trousseau). — A sclerosis of the 
medulla, distinguished by progressive paralysis and atrophy of the 
muscles of the tongue, lips, larynx, and pharynx, with increased 
mechanical and reduced electric excitability, with the reaction of 
degeneration and reduction of reflex. 

With the other scleroses, the etiology of this affection is involved 
in obscurity. The disease occurs more frequently in advanced life, 
is rare before thirty, and attacks men more than women. Bulbar 
paralysis has also been ascribed to exposure to cold, excesses, and 
fatigue, without other proof of cause than sequence. The disease is 
a degenerative atrophy which successively involves the centres of 
various cerebral nerves; hence it has been called a progressive para- 
lyses of the cerebral nerves (Benedikt). The centres attacked are, 
in the order of frequency and severity, the hypoglossus, facial, 
spinal accessory, pneumogastric, glossopharyngeal, more rarely the 
abducent, and the motor part of the trigeminus. The auditory nerve 
is never affected. 

Morbid Anatomy. — The atrophic process leads to a destruction 
of the contents of the great ganglion cells. Nuclei and protoplasm 
actually disappear to leave only granules and pigment matter. 
There is hyperplasia of the connective tissue, thickening and athe- 
roma of the vessels. The degenerative process extends into the axis 



726 



BULBAR PARALYSIS. 



cylinder of the nerves, and the muscles supplied by them suffer 
granulo-fatty atrophy. 

Though this atrophic process may not be regarded as the primary 
affection, it is impossible as yet to discover its cause. It has been 
found by Benedikt in connection with basilar meningitis, and is 
frequently associated, often as the terminal process, with progressive 
muscular atrophy, lateral sclerosis, paralytic dementia, etc. 

Symptoms. — The disease begins very insidiously, and is marked 
at first with the difficulties of speech which arise from affection 
of the hypoglossus. Sounds which require the use of the tongue suf- 
fer first: to wit, of vowels, i; of consonants, first r, later s, I, k, g, t, 
and lastly cl and n. Affection of the facial produces difficulty with the 
pronunciation of, first, u, later a, and of the consonants p, f, further 
with b, m, and v. Paralysis of the palate gives rise to the nasal 
voice, and affection of the accessory produces 
paresis of the vocal cords and muscles of the 
larynx. The lips lose power to whistle or to 
blow out a light; the face loses expression. 
The difficulty with mastication from paresis of 
the tongue and lips leads to accumulation of 
food and lets it drop from the mouth. Saliva 
is freely discharged, or must be continuously 
wiped away. The paralysis of the vocal cords 
interferes with respiration and leads to diffi- 
culties of expiration and to dyspnoea. The 
affected muscles show the same reactions of 
degeneration and fibrillar ttvitchings as in 
progressive atrophy. 
A rare variety of bulbar paralysis, which shows itself in acute 
form, occurs in connection with haemorrhages in the medulla and 
pons, from thrombus and embolus in the domain of the vertebral, ante- 
rior spinal, and basilar arteries. This acute bulbar paralysis shows, 
in connection with the signs of involvement of the cerebral nerves, 
hemiplegia with opposite facial paralysis, hemiplegia alternans ; 
or crossed paralysis of the upper and lower extremities, hemiplegia 
cruciata, with bilateral paralysis. The signs of an acute paralysis 
may occur also in connection with, though as a very rare complica- 
tion of, disseminated myelitis. The disease is then announced with 
the same irritative signs — headache, vertigo, etc. — followed by para- 
lysis of the various nerves that issue from the medulla, with rapidly 
fatal termination. 

The diagnosis rests upon the successive involvement, in regular 
progression, of various cerebral nerves, beginning with the hypo- 
glossus and ending with the trigeminus, or extending further to 




Fig. 286.— Bulbar paralysis ; 
maximum protrusion of 
tongue (Gowers). 



ACUTE ASCENDING PARALYSIS. 727 

involve the anterior cornua in the sj3inal column, in association with 
symptoms of progressive muscular atrophy. The relation is usually 
the other way. The muscular atrophy precedes the bulbar paralysis. 

Bulbar is distinguished from multiple sclerosis, or tumor with 
pressure upon the medulla, by the different advent of these affec- 
tions, and the involvement of other nerves than those affected in 
bulbar paralysis. Headache, vertigo, vomiting, convulsions, with 
affections of the auditory nerve and sensitive portions of the trige- 
minus, paralysis and contractions without muscular atrophy, belong 
to these diseases, but not to bulbar paralysis. 

The prognosis is absolutely bad. The disease extends over a period 
of two to five years, with a constant tendency to progression, though 
it may come to a standstill and seem to be arrested for several months 
at the beginning of the disease. 

The treatment consists in a use of the galvanic current and the 
subcutaneous injection of strychnia, after the manner already speci- 
fied in connection with other scleroses. 

ACUTE ASCENDING PARALYSIS. 

A paralysis which begins in the lower extremities and ascends 
rapidly to involve the body and upper extremities, in the absence 
of all discoverable lesion in the spinal cord. This paralysis was 
first specialized by Landry (1859), and is often called Landry's 
paralysis. 

Etiology. — The disease is assumed to be an infection, the nature 
of which is unknown. Support of this view is furnished in the fre- 
quent presence of enlargement of the spleen common to most infec- 
tions, and occasional attacks of fever and sweating. It is more com- 
mon in males and in the period between adolescence and maturity. 

Symptoms. — The paralysis begins as a weakness of the legs, and 
extends so rapidly as to take the patient off his feet in the course of 
twenty-four to forty-eight hours. The weakness is noticed next in 
the pelvis, and rapidly ascends to involve the whole trunk and upper 
extremities. In all cases the paralysis is pronounced ; in the lower 
extremities it is usually absolute. The process may stop at the cer- 
vical cord, but extends often to involve the medulla with the centres 
of articulation, deglutition, and respiration. The unfortunate pa- 
tient, with full consciousness, may no longer express his wants; he is 
unable to swallow and suffers attacks of dyspnoea or succumbs to 
suffocation. Sensation is affected in much less degree. The para- 
lysis may be preceded by paresthesia, especially by numbness and 
tingling in the extremities, but the sensation of touch is usually pre- 
served. The reflexes disappear and remain lost in cases rapidly 
fatal, but return gradually with recovery. The sphincters usually 



728 SPINAL HEMORRHAGE — HEMATORRHACHIS; HJ1MATOMYELIA. 

escape. Notwithstanding the intensity of the signs, there is little or 
no trophic change ; the muscles do not waste, electric excitability 
is not lost, and bed sores do not develop. 

The prognosis is very grave. The paralysis may extend to in- 
volve respiratory or cardiac centres, and thus prove fatal in the 
course of two days. The duration on the average is less than a 
week. Recovery, when it occurs, is rapid only in exceptional cases. 
As a rule it is exceedingly slow and extends over a period of several 
months. 

Treatment is of little avail, as the course of the disease is deter- 
mined by the nature or amount of the infection, and may be but lit- 
tle influenced by drugs. It is advisable to push the salicylate of soda 
and to administer warm baths. The bichloride has been recom- 
mended in small and frequently repeated doses, or, where mercury is 
contra-indicated, the perchloride of iron. 

SPINAL HEMORRHAGE— HEMATORRHACHIS; HEMATOMYELIA. 

Hemorrhage ma}' occur in any part of the cord substance or 
membranes, where it may be extra- or intrameningeal. Meningeal 
haemorrhage, haematorrhachis, is chiefly due to injury, fractures, 
falls, etc., but sometimes occurs after the straining efforts of violent 
convulsions. As miliary aneurisms do not develop in the course of 
the vessels, haemorrhage into the substance of the cord — haemato- 
myelia — is rare. But it may occur at any age from infancy to ad- 
vanced life, most frequently in adolescence and early maturity. 
Trauma is the most frequent cause. In exceptional cases haemor- 
rhage has been observed after excesses in venery. 

The symptoms depend upon the seat and extent of the effusion. 
Haemorrhage is usually announced by sudden and violent pain in 
the back and along the course of the nerves which issue from the 
seat of the lesion. Spasm, rigidity, convulsions, may immediately 
supervene and be followed by rapid paralysis, paraplegia. In ex- 
ceptional cases the brain may be affected indirectly from upward 
displacement of the cerebro-spinal fluid. Symptoms occur, as stated, 
suddenly, and develop rapidly, to reach their height in a few hours or 
days with fatal lesions, or, in favorable cases, with gradual recovery 
in the course of a few weeks. 

Diagnosis. — Meningeal haemorrhage is distinguished by the 
prominence of pain and irritation. In haemorrhage into the cord 
paralysis is the most prominent sign; fever, which develops early, 
speaks rather in favor of myelitis. 

The prognosis is always grave, and is determined early in the 
history of the case. Effusion into the cervical region is especially 



ACROMEGALY. 729 

grave. The return of sensation is a favorable sign; evidence of tro- 
phic change is unfavorable. 

The treatment is absolute rest, recumbent, with an ice bag to the 
spine, and attention to the secretions. A subcutaneous injection of 
ergotin or sclerotinic acid may secure contraction of the vessels and 
check the haemorrhage. 

SYRINGOMYELIA. 

Syringomyelia (ffvpiyg, pipe) ; gliomatosis of the cord. — A dis- 
ease marked by anaesthesia and muscular atrophy, and distinguished 
by the presence of cavities in the spinal cord. These cavities have 
been variously interpreted as arrest of development, defective closure, 
Olivier (1827) ; the results of sclerosis, Hallopeau ; neoplasm, glioma, 
Grimm (1869) ; in Brittany as the result of leprosy. The disease 
was associated with distinct symptomatology by Kahler and Schultze 
(1882). 

Morbid Anatomy. — The cavities are usually found in the poste- 
rior parts of the cord, and result clearly from a glioma or gliosarcoma 
which has broken down and disappeared. The cavity is generally 
lined with a delicate covering layer containing glia cells, and not in- 
frequently communicates with the central canal of the cord. 

Symptoms. — Syringomyelia is usually announced with palles- 
thesia, especially with diminution or loss of sensation to pain 
and heat. Thus burns are not felt, and are discovered only by the 
destruction of tissue. Asmus reported a handsomely illustrated 
case (Bibliotheca Medica C. Heft 1), marked also by anaesthesia of 
the conjunctiva and cornea. The sense of touch and the muscular 
sense are commonly unaffected. The atrophy of muscle occurs 
later ; it shows itself in the hand and shoulder, and advances in 
the order of progressive muscular atrophy. Trophic changes are 
common. Surfaces of the body may be cold and cyanotic ; the joints 
may swell. The patient succumbs to bed sores, cystitis, and maras- 
mus. 

The diagnosis rests upon the loss of sensation of heat and pain, 
with preservation of the sensation of touch, and the characteristic 
muscular atrophy. The arthropathies, in distinction from tabes, are 
chiefly confined to the upper extremities (Sokoloff). 

Treatment is wholly symptomatic. 

ACROMEGALY. 

Acromegaly (aupos, end, pisyaX?j, great). — A disease distin- 
guished by hypertrophy of the bones and tissues of the hands, feet, 
and face, with headache, drowsiness, melancholy, sweating, and 
thirst. The alterations were first described by Pierre Marie and 



730 RAYNAUD'S DISEASE. 

Souza-Leite (1891) with a record of forty-eight cases. Osborne 
(1892) reported the eighth case observed in this country. Acrome- 
galy usually occurs between fifteen and thirty- five, and may be ob- 
served in several members of the same family. The enlargement of 
its bones imparts to the face a peculiar expression. The chin is 
prominent ; the whole lower jaw protrudes. The trunk and the long 
bones are unaffected, though there is usually anterior dorsal curva- 
ture with compensatory lumbar lordosis. The stature is heightened, 
the abdomen projects. The hands are very much broadened, the 
fingers are uniformly enlarged ; the nails, broad and short, scarcely 
* reach the ends of the fingers. Among the curious anomalies of 
this condition are enlargement of the tongue, polyuria, sweating, 
and disturbances of special senses. The condition is ascribed to 
lesions of the spinal cord allied to those of syringomyelia. 

morvan's disease. 

A trophic disease, distinguished by destruction and deformity of 
the ends of the fingers. The affection was first described by Morvan 
(1883), later by Charcot. The disease shows all the signs of inflam- 
mation except pain. There are heat, redness, and swelling, but, as a 
rule, entire absence of pain, analgesia. The ends of the fingers suf- 
fer necrosis, the nails fall out, the hands may become blue. Anaes- 
thesia and atrophy occur subsequently. The course is very slow ; 
months, even years, may lapse while the disease extends from one 
finger to another. 

The pathology is obscure. The affection is considered a sclerosis 
of trophic centres in the spinal cord. 

Diagnosis. — Morvan's disease is distinguished from the destruc- 
tive dactylitis of syphilis by the signs of syphilis elsewhere and by 
the absence of analgesia in syphilis ; from leprosy — if it be not lep- 
rosy itself — by the signs of leprosy elsewhere, the patches and nod- 
ules over the body, and by the affection of the lower extremities in 
lepra ; from syringomyelia by the absence of necrosis of bone, the 
presence of sensation, and the progressive muscular atrophy of this 
disease. 

The prognosis is unfavorable. 

The treatment is wholly symptomatic. 

RAYNAUD'S DISEASE. 

A gangrene of the extremities, sometimes of other parts of the 
body, distinguished by symmetrical distribution. The affection was 
first described by Raynaud (1862). It is considered a vaso-motor 
neurosis. The disease begins with pallor and paresthesia in the first 
phalanges of the fingers or toes, sometimes also in the tip of the 



PROGRESSIVE DYSTROPHY. 731 

nose and upper parts of the ears, which soon become cyanotic and 
cedematous. Gangrene and sloughing may supervene. 

Diagnosis. — The effects of frost bite, which may simulate the 
condition, disappear with warm weather ; the symptoms of Ray- 
naud's disease, though aggravated by cold, persist. 

The prognosis varies according to the extent and rapidity of 
spread of the disease. Recovery is possible in even the worst cases. 

Treatment is wholly symptomatic. Vascular spasm may be re- 
laxed by belladonna and the bromides, the action of the heart sus- 
tained by digitalis. Pain may be so severe as to require the use of 
morphia. The nervous system may be supported by strychnia. The 
general health must be held up by tonics. 

brown-sequard's paralysis. 

Brown- Sequard's paralysis is a paralysis of motion on the same 
side and of sensation on the opposite side of a lesion in the cord — 
i.e., a hemiparaplegia with crossed anaesthesia. The condition is 
attributed to a lesion in the lateral half of the cord, and is explained 
by damage to the motor fibres in their downward course and to sen- 
sory fibres before decussation in their upward course. Crossed sen- 
sory and motor paralysis occurs only in injury or disease of the cord 
as low as, and below, the middle dorsal region. Motion, by trans- 
fer of nerve force through decussating fibres from the opposite side 
of the body, usually returns, while sensation remains lost. 

Horsley accepts the symptomatology, but doubts the interpreta- 
tion. 

The prognosis is grave, yet cases of recovery have been reported. 

PROGRESSIVE DYSTROPHY. 

Dystrophy {SvZ, mis-, rpocpeia, nourishment) of muscle is a term 
employed to distinguish disease dependent upon affection of the mus- 
cle independent of nerves, that is, of myopathic as distinguished 
from neuropathic origin — a distinction that is by no means actually 
established as yet. The visible distinction lies in the fact that atro- 
phy is attended with distinct reduction in volume, while dystrophy 
may be attended with an apparent increase in volume. Atrophy is 
distinguished by the occurrence of fibrillary twitchings and the pre- 
sence of the reaction of degeneration in at least part of the affected 
muscles. Dystrophy is distinguished by the fact that the electric, 
faradic, and galvanic irritability is reduced or lost without a show 
of the reaction of degeneration. The chief types of dystrophy are : 
(1) pseudo-hypertrophy, (2) juvenile dystrophy, (3) hereditary atro- 
phy, (4) facial atrophy. 

1. Pseudo-hypertrophy of muscle is, as the name implies, 



732 



PROGRESSIVE DYSTROPHY, 




only an apparent increase of volume, as the muscular structure itself 
is reduced in amount and substituted by the abundant development 
of interstitial fat. The condition is commonly associated with pro- 
gressive muscular atrophy, and shows itself in the lower half of the 
body, while the atrophy advances in the upper half. The disease 
alwa} T s shows itself in early life— four times as frequently in boys — 
during the period of development, and is most frequently first ob- 
served in the first attempts to walk. The muscles of the calf of the 
leg are earliest and most affected. The enlargement may be very 

great, so that the leg of the boy 

is as big as a man's and is out 
of all proportion to the rest of the 
body. The infraspinatus is next 
most frequently affected, and is 
at times so much enlarged as to 
be mistaken for the scapula it- 
self. The difficulty of locomotion 
is especially marked in the at- 
tempt to climb stairs — the child 
must pull itself up by the banis- 
ters — and is very manifest in at- 
tempts to lift itself from the floor, 
an act which is accomplished 
only by the use of all four ex- 
tremities. 

Especial stress is laid, in di- 
agnosis, upon the great size of 
the infraspinatus with atrophy of 
H the latissimus dorsi ; next upon 
the enlargement of the muscles 
of the calf and loss of knee jerk. 
^J™***" ' \ The disease shares the grave 
L — — ^^^H^M prognosis of other forms of 

Fia 287 -Pseudo-hypertrophic paralysis; muscular atr0 phy. It is pro- 
big calves ol legs (Putzel). ^ J r 

gressive. After loss of the power 
of standing, seven years is about the longest duration of life. 

The treatment is the same as that of progressive muscular atro- 
phy. 

2. Juvenile Dystrophy occurs in adolescence and begins in the 
muscles of the upper extremity. It shows itself with the same in- 
crease in volume and diminution in force. The muscles especially 
affected are the deltoid, supra- and infraspinatus, teres major and 
minor, triceps, tensor facise latse, sartorius, gastrocnemius. With 
the exception of the supinator longus, the muscled of the forearm 



TETANY. 



733 



usually escape. Lipomatosis is not so pronounced as in pseudo- 
hypertrophy, but sclerosis is more common. 

3. Hereditary Atrophy is a subvariety which occurs in later 
childhood and adolescence, is hereditary and affects a number of 
members of the same family, but otherwise is not different from 
forms already described. 

4. Facial Atrophy — Duchenne (1872) — attacks chiefly the or- 
bicularis oris ; later the orbicularis palpebrarum, frontalis, levator 
nasi, zygomatici, and risorius, and may extend to involve the mus- 
cles of the shoulder and arm and even of the lower extremity. It is 
unilateral. The alteration thus effected in the face changes thephy- 



1 




Fig. 283. — Pseudohypertrophic paralysis; 
attempt to rise from floor (Putzel). 



Fia. 289.— Pseudohypertrophic paralysis; 
patient ' ' climbing up his thighs ' ' (Putzel) . 



siognomy and gives the face the appearance of a mask. The fact 
that the atrophy occurs in youth, is hereditary, and coincides" with 
sclerosis, lipomatosis, and hypertrophy, allies it to, or makes'of it but 
a subvariety of, the dystrophies already described, from which it dif- 
fers only in the fact that it first affects the face. 

TETANY. 

Tetany (reivoo, to stretch). — A disease characterized by painful 
cramp or spasm in the extremities, especially in the flexors, with ex- 
cessive excitability of the motor nerves to mechanical or electrical 
irritants. 



734 TETANY. 

History. — Though described a half -century ago, the distinctive 
features were first distinctly emphasized by Trousseau, who gave it 
the name tetanilla, diminutive of tetanus. Corvisart (Lucien, 1852) 
first called it tetany. 

Etiology. — Tetany is a disease of early life. It shows itself in 
infancy, and occurs with especial frequency in the first and second 
decades of life. At this period the disease is more frequent in males. 
After the age of twenty the ratio is reversed. Tetany appears to be 
a toxaemia, the result of exhausting discharge, though there is no 
proof for this view. It supervenes most frequently upon diarrhoea 
and lactation. In children it is connected with rickets ; sometimes 
it follows attacks of typhoid fever, measles, small-pox, rheumatism, 
pneumonia. A curious sequence, too frequently observed to be a 
mere coincidence, is the occurrence of tetany after excision of the 
thyroid gland. Tetany is liable to develop within ten days after re- 
moval of the whole thyroid gland. 

Symptoms. — The disease is usually announced suddenly, with 
spasms in the hands and feet. The hand is cramped to assume a 
posture so distinctive as to be called the position of tetanus. The fin- 
gers, extended upon their own joints, are flexed upon the meta- 
carpus. The thumb is fixed against them ; the wrist is slightly 
flexed. Thus the hand is brought into the so-called obstetrical hab- 
itus, as for introduction into the uterus to perform flexion. The 
feet are extended and inverted, to assume the position of talipes 
equino-varus. The toes are flexed, the knees extended. The spasm 
may extend to involve the muscles of the trunk ; in severe cases, of 
the face ; and in extreme cases, of the eyes and tongue. Sensations 
of numbness and tingling may precede the spasm, which, when 
fully developed, is always attended by pain. The attacks are par- 
oxysmal and apparently spontaneous. They may occur in sleep. 
The heightened excitability is especially observed in response to a 
blow. A tap upon a muscle is followed by muscular contraction. 
This quick response constitutes the so-called Trousseau phenomenon. 
The compression of a nerve, in the act of compressing an artery, pro- 
duces spasmodic contraction in the course of a few minutes. Some- 
times this phenomenon is absent. Electric excitability is so much 
heightened that a current from a single cell produces contraction. 
The disease is intermittent, remittent, or more or less continuous ; it 
may last but a few days or continue for several weeks, in exceptional 
cases for several months. Recurrence is not infrequent. 

TYiq prognosis is favorable. Tetany is distinguished from tetanus 
by the cause of tetany — diarrhoea, lactation, and exposure to cold ; by 
the occurrence of spasm first in the hands and feet. Tetanus begins 
in the jaws. The obstetrical posture of the hand is peculiar to 



TETANY. 735 

tetany. Hysteria is unilateral ; tetany is always bilateral. Epilepsy 
is attended with loss of consciousness and clonic convulsions. 

Treatment is the relief of the cause. Diarrhoea is arrested by 
appropriate means ; lactation is stopped ; rickets is relieved with 
phosphorus and cod-liver oil. Severe spasms may call for chloral, 
or even subcutaneous injections of morphia ; milder cases yield to 
the bromides, half a drachm in a glass of water three times a day. 
In nocturnal tetany no remedy is so useful as a dose of digitalis at 
bedtime (Gowers). 



CHAPTEE XIII. 

DISEASES OF THE BRAIN. 
APOPLEXY. 

Apoplexy {a7to7t\rj6GGo, I strike down). — Sudden loss of conscious- 
ness from brain disease, with abolition of motion, sensation, and of 
special sense. The term as originally employed was wholly symp- 
tomatic ; but as in the course of time so many cases were found to 
be due to haemorrhage in the brain, it got gradually a wider range, 
in that it was applied to rupture of blood vessels in other organs ; so 
the older writers spoke of apoplexy in the lungs, kidneys, retina, 
etc. 

Brain apoplexy does not necessarily result from haemorrhage, as 
the same stroke may follow embolus or thrombus of the cerebral 
arteries. Hence apoplexy may occur in consequence of rheumatism, 
alcoholism, and syphilis. An apoplectiform stroke may be the result 
of trauma, uraemia, poisoning by alcohol, chloral, opium, prussic 
acid, etc., so that a differential diagnosis becomes a necessity in 
every case. 

Etiology. — True apoplexy in the majority of cases means cere- 
bral haemorrhage. Haemorrhage implies a weak vessel and an in- 
creased force behind it, one or both. The first is by far the most 
important factor. The action of the heart, however strong, cannot 
break a sound vessel ; it might weaken it in the course of time and 
then finally break it. Frequently the increase in the force of the 
heart is a struggle against resistance from disease of the vessel, 
which prepares it for rupture. 

The most important factor in connection with ordinary cerebral 
haemorrhage is age. Four-fifths of cases occur after the age of 
forty, males preponderating over females in the proportion of three 
to two. If haemorrhage from all sources be considered, the propor- 
tion is greatest in early life, infancy and about birth. The rupture 
here, however, concerns the meningeal vessels, as the result of 
strains connected with parturition. 

Heredity plays a role of some importance, in that apoplexy oc- 
curs in certain families and is absent in others. Weak arteries may 



APOPLEXY. 737 

be inherited as well as weak eyes, weak stomachs, and weak brains. 
Weak arteries bulge and break quicker under the same strain. 
Short, thick-necked, square-set, red-faced, heavily built men, the so- 
called homines quadrati, are popularly believed to have a special 
liability to apoplexy. They are said to have the apoplectic habit. 
The reverse is true. More often thin men of spare habit have 
weaker vessels in the brain. No outside condition, as accumulation 
of fat, atheromatous degeneration of radial or temporal arteries, 
arcus senilis, etc. , indicates any greater tendency to apoplexy. Out- 
side may coincide with inside atheroma and aneurism ; the brain 
vessels may still not rupture. More frequently the conditions are 
independent of each other. 

True apoplexy in the brain substance remains a disease of age. 
When it occurs earlier, in adolescence or maturity, it is the re- 
sult of conditions which precipitate the arterial changes of age — 
chiefly alcoholism, sj-philis, gout, and Bright's disease — so that the 
common expression, quoted elsewhere, "a man is as old as his ar- 
teries,' ' has foundation in fact. The walls of the vessels suffer 
particular change in age. It is a question whether the change be- 
gins in the intima or the adventitia. In either case it is expressive 
of failing nutrition, which is felt in the blood vessels first. This 
failing nutrition may manifest itself in the blood vessels generally 
over the body, to constitute the condition known as arterio-capillary 
sclerosis, whereby, owing to the resistance and lack of resilience of 
the walls in the finer vessels, extra work is thrown upon the heart. 
The solution of the cause of the failing nutrition of age is the solu- 
tion of the problem of life itself. 

Fatty and atheromatous change occurs in the great blood vessels, 
first and most markedly in the aorta. This chalky, fatty degenera- 
tion may affect also the cerebral arteries and lead to final mpture. 
More frequently a peculiar change is noticed in the finer blood ves- 
sels given off in the substance of the brain. The wall of the vessels 
weakens in spots and bulges under pressure, to form minute, so- 
called miliary aneurisms. 

Charcot and Bouchard demonstrated in the brain of apoplexy 
almost universally the presence of these miliary aneurisms, the rup- 
ture of which caused cerebral haemorrhage. There are reasons why 
the vessels in the brain soonest suffer this change. In the first place, 
they are surrounded by semi-solid, almost diffluent substance, so 
that they lack external support. In the second place, fine arterioles 
are given off directly from large trunks, so that delicate-walled 
vessels must sustain the pressure of thicker trunks or tubes. Mili- 
ary aneurisms are detected on the walls of the smaller vessels by 
placing the brain substance with its clot in water, and gently agitat- 
47 



738 APOPLEXY. 

ing the water to wash away everything else. The twigs with their 
aneurism, like grains of red sand or minute drops of blood, float out 
to become manifest. As many as two hundred aneurisms have been 
counted in a single brain, rupture of any of which produces apo- 
plexy. The tendency of the condition to recurrence is thus ex- 
plained. The break is sudden, but the process which leads to it is 
slow, requiring months and years for its full development. 

Any vessel in the brain, the great vessels at the base of the 
brain, arteries of the circle of Willis, or their immediate branches, 
may break. The rupture occurs most frequently in branches of 
these last-mentioned branches in the substance of the brain. Haem- 
orrhage may occur in any part of the brain substance. It does oc- 
cur most frequently about the great ganglia and the island of ReiL 
A branch of the middle cerebral artery breaks so often as to have 
been called by Charcot the artery of haemorrhage. Haemorrhage 
may occur in the cortical substance, in the pons, medulla, most rarely 
in the cerebellum. The quantity of blood which may escape varies: 
a drop or two may exude, or such a mass be poured out as to tear 
up the brain substance, break into the ventricles, and form a pool in 
the brain. Blood may pour out en masse at once, or may ooze out 
gradually ; or haemorrhage may cease, to recur again and again. 

Should the patient survive the shock and pressure, the clot under- 
goes the same subsequent changes as in other parts of the body. It 
may become encj'sted and shut off from the rest of the brain. Its 
contents may be transformed into a clear fluid. Such cysts are fre- 
quently seen upon autopsy. The blood may be entirely absorbed, 
when connective tissue may fill up the breach to leave a scar, dis- 
coverable also on autopsy. Slight losses of brain substance may be 
substituted by other cells and little or no damage may be left. The 
slightest loss is usually appreciated by the patient as loss of energy 
—so many battery cells have been cut out. 

Sometimes irritative changes set in ; sometimes secondary de- 
generation takes place about the clot ; and the process may extend 
to the pons, medulla, and cord, with consequent impairment or loss 
of function. It is rare that a lesion may disappear to leave no trace. 
A severe lesion may take life at once, or the patient may be para- 
lyzed and recover to suffer subsequent attacks. 

Symptoms. — An attack of haemorrhage announces itself, as a 
rule, without symptoms. The patient is pursuing his ordinary 
avocation when he is suddenly, without warning, stricken down. 
In a few cases there may be premonitions — headache, vertigo, neu- 
ralgic pains. Premonitions occur more frequently in connection 
with kidney disease, and have been, in the history of the individual, 
frequently present before. Sometimes the attack occurs in sleep. 



APOPLEXY. 739 

It occurs frequently in the bath. It may be directly provoked by 
emotion, or a strain, as at stool. In certain cases there is felt a 
sensation of numbness, lameness, in an arm or leg. Sometimes the 
patient rises to fall unconscious ; or is able to go about, to reach 
, home and go to bed, and send for a physician before the lapse into 
coma. These cases have been denominated "ingravescent" apo- 
plexy. Certain cases are preceded by violent pain in the head. 
The first signs may precede the coma by several days These vary- 
ing conditions may be explained by the quantity and rapidity of the 
haemorrhage. More frequently the patient is found unconscious, 
totally paralyzed, bereft of sensation, in whatever position he may 
have fallen, in a state of profound coma. The face may be flushed, 
dark or pallid, or cyanotic ; sometimes it is covered with sweat, 
which must be constantly mopped away. The surface may be cold 
or hot. The pulse may be full and bounding — this is especially the 
case in kidney disease ; or feeble and fluttering, as after a profound 
shock. The pupils may be dilated or contracted ; they are most fre- 
quently dilated, especially in profuse or ventricular haemorrhage ; 
they may be contracted to the size of a pur's head, especially in 
haemorrhage in the pons ; they may be unequal — but whether di- 
lated, contracted, or unequal, they are always irresponsive to light. 

Respiration is stertorous ; the patient snores. The cheeks flap. 
The alae nasi may be sucked in by inspiration. The lips are blown 
out with expiration. Respiration is usually retarded ; its rhythm 
is often irregular ; it sometimes stops and is resumed with a series 
of more rapid acts, preceded by one longer- drawn inspiration — the 
Cheyne-Stokes respiration. The limbs, lifted from the body, fall 
like dead weights. The discharges may be voided involuntarily and 
unconsciously ; more often they are retained and must be voided 
artificially. 

The coma and paralysis may last for several hours, the greater part 
of a day, or several days. During this period the patient is uncon- 
scious of everything about him. The sound of a familiar voice, as of 
a wife or child, may excite a responsive groan or mutter. The patient 
may be able to swallow. Deglutition is usually impossible at first, and 
imperfect for some time. Gradually there is dawn of consciousness. 
The sound side moves. Deglutition is less difficult. Speech is, if 
possible, thick. Now it is seen that one side of the body — the side op- 
posite the lesion — is paralyzed. There is h em iplegia. The paralyzed 
side is to all appearance normal ; it is usually somewhat cooler, may 
sweat more easily and profusely, but it is totally bereft of motion 
and sensation. Sensation returns in the course of a few hours or 
days, but motion is lost. During the existence of coma, and in the 
presence of universal paralysis, it may have been impossible to local- 



740 



APOPLEXY. 



ize the lesion. Sometimes, however, the eyes are turned in the same 
direction. They both look to the right or left as far as may be, but 
always, or very nearly always, toward the lesion in the brain and 
away from the paralyzed side of the body. This "conjugated devia- 
tion of the eyes " indicates lesion of the gyrus angularis with spas- 
tic contraction, which is itself a bad sign. Sometimes the head also 
is twisted over in the direction toward which the eyes look. It may 
be brought back to the median line with some degree of force, some- 
times with manifest expression of pain ; but, left alone, it returns 




Fig. 290.— Forms of hemiplegia : 1, common type of hemiplegia, from haemorrhage in the 
neighborhood of the corpus striatum— the shaded parts indicate the distribution of the paralysis ; 
2, hemiplegia in lesions of the crus cerebri; 3, hemiplegia in lesions low down in pons Varolii 
(Shaw). 

as before. So the eyes may be made to follow a light to the median 
line, but not beyond, when they, too, assume the former direction. 
The paralyzed side may show, instead of less, more motion, to con- 
stitute actual rigidity. The hand is found clenched and flexed 
upon the forearm, the forearm upon the arm. Less frequently the 
foot is extended and inverted. This rigidity may come on early 
during the coma, or within a few days after the stroke, or later 
after the lapse of two or three weeks. Whether the rigidity be early 



APOPLEXY. 741 

or late, it constitutes always a bad sign. Early rigidity speaks 
against recovery with life, late rigidity against recovery of use of 
the limb. 

Diagnosis. — Haemorrhage may at times be differentiated from 
embolus by the fact that embolus occurs more particularly in 
adolescence and maturity, and in consequence of rheumatism or 
some infection which has produced a lesion of the heart. The heart 
may be found enlarged in its diameters, and changes may be audible 
in its sounds. Otherwise haemorrhage and embolus may not be 
separated. Thrombus occurs more particularly in gout, renal cir- 
rhosis, and syphilis, which conditions may be recognized by evi- 
dences of these diseases elsewhere. Uraemia occurs in connection 
with kidney disease, which may have been plain in the previous his- 
tory. Albuminuria may be recognized by the withdrawal of urine 
at the time of examination. Uraemia distinguishes itself by the 
predominance of convulsions over comatose states. Alcoholism may 
be recognized by the history of the individual, by the odor of the 
breath, by the proximity of vomited matter. Great caution must be 
exercised concerning these things. Mortifying reflections have been 
cast upon medical men who have carelessly permitted patients with 
organic lesion of the brain to be carried to station houses as " dead- 
drunk." It must be remembered that drunkards are especially 
liable to cerebral haemorrhage and uraemic attacks. A man in coma 
should always be sent to a hospital until his true condition may be 
ascertained. Trauma may be discovered by examination of the 
skull, or may reveal itself later in the history of the case. 

Time alone may accurately determine the prognosis. Most 
patients succumb to the first stroke. Coma which lasts longer than 
forty- eight hours is usually fatal. The immediate danger is best 
recognized by means of the thermometer. There is time to make 
observations, as death, though it may occur quickly, is never imme- 
diate as in heart disease. In the initial shock the temperature falls 
one or two degrees. The lower it falls the worse is the outlook. 
It should begin to rise in the reaction in the course of a few hours, 
and remain about 100° or 101° for a few days. The more rapidly it 
approaches the normal grade the better is the outlook. The dura- 
tion of life in these cases may be most accurately determined by the 
thermometer. Temperature which rises from a level of 100°-102° ? 
where it has stayed for several days, to 105° or 106°, is pre-agonal. 

What damage will be left may be determined only by time. 
After a single stroke individuals have remained free for twenty 
years, long enough to have died of extreme old age. There is, how- 
ever, constant liability to another stroke The sword of Damocles 
literally hangs over the head of an individual who has once suffered 



742 EPILEPSY. 

a cerebral haemorrhage. When the patient recovers, the leg recovers 
first, but long after the patient may go about on foot the arm still 
swings helpless at the side. In general, left-sided hemiplegias are 
worse than right. 

Treatment. — A patient affected with apoplexy should be placed 
in a recumbent posture, the clothes loosened about the neck and 
body, the body kept warm, and the head cool by cold water or an ice 
bag. Stertor, which often depends upon prolapse of the tongue and 
occlusion of the glottis with reflux of saliva, may be usually largely 
relieved by placing the patient upon the right side, in such a position 
that the saliva may drain away (Bowles). 

To bleed, or not to bleed — that is the question. Venesection was 
formerly unanimously employed in case of high arterial tension. A 
flushed face and bounding pulse were said to call imperatively for the 
letting of blood. This condition meets its explanation in our day 
better by the state of the kidneys, which causes the whole mischief 
in the heart and brain. It is questionable if blood-letting be ever 
justifiable in a case of haemorrhage in the brain. A meningeal 
haemorrhage may be relieved by surgery. No drug can dissolve 
blood clots in the brain. 

After the subsidence of acute symptoms, muscles may be kept 
from wasting by massage and faradization, which best substitute 
absent or failing nerve force. Warm baths always give great com- 
fort. States of irritation may be allayed by the bromides, gr. xxx. in 
half a glass of water. Sleep is best secured by trional, gr. xv.-xx. 
in a cup of hot tea at bedtime. Still later on some benefit may be 
derived by the subcutaneous injection of strychnia, preferably the 
nitrate, given in dose of one-one-hundredth of a grain, with the 
dosage gradually increased to tolerance. Phosphorus, the compound 
syrup of the hypophosphites, may be given with it. Peace of mind, 
when possible, is a great help. The panorama of travel may divert 
the mind from its own organ. 

EPILEPSY. 

Epilepsy (£7tiXapi/3avoD, to seize). — A fine cortical lesion, charac- 
terized by paroxysms of loss of consciousness and convulsions (mo- 
mentary tonic and subsequent clonic convulsions) of the whole body, 
with, as a rule, dilatation of the pupils, which are irresponsive to 
light, and general loss of the reflexes. A subvariety marked by 
localized convulsions, unattended with loss of consciousness, is dis- 
tinguished as Jacksonian epilepsy. Other states simulating, but 
differing in essential particulars, are called epileptoid, in distinction 
from the true disease. Explosions due to organic disease are called 
symptomatic; they do not fall under the head of true epilepsy. 



EPILEPSY. 74:3 

History. — Epilepsy was known in the most remote antiquity, 
when it was distinguished, on account of its dreadful aspect, as the 
sacred disease of supernatural origin. Hippocrates wrote an entire 
book " De Morbo Sacro," and described it, on account of its frequency 
in youth, as a child's disease. The term epilepsy was not used by 
Hippocrates or Galen, but was first employed in the tenth century 
by Avicenna. Aretaeus and Ccelius Aurelianus vividly described its 
symptomatology. Morgagni made the first attempt to discover its 
anatomical basis. Tissot (1770) wrote the first elaborate monograph. 
Esquirol, Calmeil, thoroughly described the disease. Delasiauve 
(1852) and Schroder van der Kolk (1858) again studied its pathologi- 
cal anatomy. Brown- Sequard, in his experiments in the production 
of the disease in animals, produced the disease by traumata. Jack- 
son eliminated a special form. Ferrier and Horsley recommended 
and practised the exsection of cortical substance of the brain in 
treatment. 

Etiology. — Epilepsy is a chronic affection which consists of an 
underlying condition and characteristic paroxysmal explosions of 
very short duration, with varying intervals of complete absence. 
The underlying condition is induced by various causes: 1. Heredity 
in one-third of the cases, wherein the disease may alternate with other 
neuroses. Thus insanity, hysteria, alcoholism, migraine, may ap- 
pear in the posterity as epilepsy. In one case recorded by Gowers 
fourteen members of a family were epileptic in the course of four 
generations. Hereditary forms occur before twenty. 2. Age; three- 
fourths of all cases begin before twenty, one-half between ten and 
twenty, one-eighth under three years of age. 3. Sex; females are 
rather more frequently affected, in the proportion of six to five. 4. 
Trauma. Epilepsy may be acquired by injury of peripheral nerves, 
by disease of internal organs, especially the brain. Proof of the ac- 
quisition of the disease by injury was furnished in the experiments 
of Brown-Sequard, especially with guinea-pigs. In these animals 
blows upon the head produce convulsions, which subside to leave the 
animal in apparent health. Certain regions of the surface of the 
body now become so sensitive as, when irritated, to produce epilepti- 
form convulsions. The cheek and front of the neck — region of dis- 
tribution of the trigeminus and occipital nerves — constitute these 
so-called epileptogenous zones. The curious fact was now observed 
that the progeny of these artificially epileptic animals inherit the 
disease. When both parents had been made epileptic, no one of the 
young escaped. 5. Epilepsy may also be excited directly by disease 
of the brain and spinal cord, in which are situated certain centres, 
the excitation of which produces convulsions, and, through the vaso- 
motors, spasmodic occlusion of the arteries, especially of the brain. 



744 EPILEPSY. 

6. Epilepsy may be excited by gross irritation of the cortical 
substance. These cases are distinguished by forcible movement of 
a particular member innervated from the seat of irritation. A more 
extensive irritation involves also the opposite side, or more extensive 
groups of muscles, or the whole body. 7. Chemical poisons, alcohol, 
especially absinthe, urea, toxines (eclampsia), etc., produce epileptic 
or epileptiform attacks. 

True epilepsy, however, requires the exclusion of all discoverable 
organic disease or chemical poison. Epilepsy, as a neurosis, so- 
called, i.e., a disease without discoverable lesion, is assumed to de- 
pend upon discharging lesions from cortical centres rendered instable 
of nerve force by heredity or acquisition. This instability or irrita- 
bility of nerve cells or centres constitutes the underlying condition, 
which may be definitely determined in about one- third of cases. 

The immediate explosion is produced by some exciting cause. 
Infantile cases are generally due to rickets. They are usually 
ascribed to dentition, defect or delay in which is chiefly caused by 
rickets. In very early life fright is a frequent cause, but the fright 
is often overlooked or forgotten because of the long interval which 
may follow. Where the fit follows the fright immediately it is 
hysterical rather than epileptic. The first outbreak may be caused 
by some infectious disease, especially by scarlet fever with and 
without nephritis, more rarely measles, and still more rarely by 
typhoid fever. Cases which develop later in life may owe their ori- 
gin to poisoning by alcohol, tobacco, or other excess or dissipation. 
Syphilis is a frequent cause of symptomatic epilepsy. Any one of 
these exciting causes may suffice to produce epilepsy in the presence 
of the underlying state. 

Epilepsy shows itself in two distinct forms, as major and minor 
attacks, the so-called grand and petit mat. In the major, which 
constitutes the common form of the disease, the attack is usually 
preceded by a distinct sensation known as the aura. The aura was 
described by Galen as a cool breath or breeze which started in the 
extremity and travelled to the brain, where it produced the loss of 
consciousness and convulsions. Such an aura is present in only the 
minority of cases. But some peculiar sensation or impression, as 
affecting the sensitive, vaso-motor, or motor nerves, the special senses, 
or the mind itself, is observed in at least half of all the cases. The 
sensitive aura may show itself as a paresthesia, pain, or anaesthe- 
sia in some part of the body, especially the extremities, the toe, the 
thumb, the epigastrium, whence it travels rapidly to the head or 
heart. The vaso-motor aura is distinguished as a flushing or pallor 
or mottling of the face or other part of the surface. The motor aura 
shows itself in twitching motions of individual muscles or groups of 



EPILEPSY. 745 

muscles, grimaces, sudden spasms of the extremities, contortions 
of the head, trunk, circular movements, stoppages of speech, etc. 
The aura of spjecial sense concerns especially sight and hearing, 
as flashes, sparks of light, sudden darkness, display of colors, espe- 
cially of red, or noises, a roll of thunder, rumble of wagons, tin- 
nitus, sounds of voices, etc. Hallucinations may be thus produced. 
Sauvages saw a woman to whom everything was magnified ; a phy- 
sician's watch was a cartwheel, etc. Per contra, Hammond saw a 
case in which for a certain period everything was reduced in size. 
Aurse of smell and taste are much more infrequent, as is also psych i- 
cal aura, which shows itself as a sudden confusion, incapacity, or 
excitement. 

Neither the absence nor the presence of the aura absolutely indi- 
cates an attack. In at least half the cases all aura is absent. The 
absence of aura in these cases may be attributed to the sudden- 
ness of the stroke. There is no time for the perception of an aura, 
which would require at least the fraction of a second. Interesting 
are those cases in which an aura may be intercepted or cut off and 
an explosion prevented. Thus a boy carried a string in his pocket, 
with which, by quickly winding it about his thumb, he could often 
prevent an attack. The swallowing of a handful of salt may inter- 
cept a stomach aura in the same way. Firm pressure upon a particu- 
lar part of the body, as against a mantelpiece or piece of furniture, 
may have the same result. Subsequent attack after such interrup- 
tion is wont to be more severe. 

Symptoms. — The attack proper occurs like a seizure, suddenly. 
The patient, in whatever situation or position, sinks unconscious to 
the ground. The fall may be attended or preceded by a cry, a pecu- 
liar, indescribable groan, of which the patient is unaware, though it 
is' said that he sometimes hears and remembers it. The epileptic cry 
is a mechanical expression of air from the chest through a spasmodi- 
cally contracted glottis; but, with or without the cry, the patient falls 
as if stricken by lightning, falls precipitately, and, from preponder- 
ance of weight, usually forward upon the face. There is total 
abolition of every sense and sensation, hence damage is often in- 
flicted by the fall itself. Patients have been drowned in a tub of 
water, or more frequently burned by fall into a fire, until the face, 
feet, or other part of the body have become charred. At the moment 
of the stroke the face is blanched from spasmodic closure of the arte- 
ries. Delasiauve had the opportunity to see during an ophthalmo- 
scopic examination the same blanching of the retina at the moment 
of attack. In this moment of pallor the whole body is rigid. There 
is for a few seconds a complete tonic, tetanic spasm. The breath 
stops, the heart's action is arrested. 



746 EPILEPSY. 

Almost at once the scene changes. The face flushes, the color 
deepens sometimes to the deepest cyanosis, the vessels stand out in 
the neck, the eyes protrude, as Aretseus said, like those of a strangu- 
lated bull, and convulsions, more or less violent, agitate the entire 
body. The convulsions distinguish themselves by their tumultuous 
character. The head is tossed from side to side, the eyes roll in their 
orbits; the tongue is protruded and withdrawn; it is of ten caught and 
cut between the teeth, so that the saliva, churned into foam, is tinged 
with blood and oozes out, thus colored, upon the face. The discharges 
may be voided unconsciously. The pupils are usually dilated, some- 
times contracted ; they are always irresponsive ; with returning 
consciousness they may show for several minutes alternate contrac- 
tion and dilatation every few seconds. As the convulsions progress 





Fig. 291.— Epilepsy ; period of tonic convulsion (Mercier). 

the body becomes covered with sweat. Gradually, in the course of a 
few minutes, though the time seems much longer to spectators, the 
convulsions grow weaker, while the loss of consciousness still per- 
sists. With the entire subsidence of the convulsions some degree of 
consciousness returns. The patient, dull and exhausted, may fall 
into deep sleep, from which he awakens without the slightest recol- 
lection of the attack. 

There is every variety in the frequency of recurrence. Attacks 
may occur only at intervals of years. The first attacks are, as a 
rule, the furthest apart ; subsequent attacks have shorter intervals. 
Attacks may occur daily or may be repeated several times a day. 
Such frequency of attack is usually due to organic disease. 

Epilepsia minor, petit mal, shows itself in much greater variety 
of form. A common expression is a very temporary arrest or 



EPILEPSY. 7^7 

obscurity of consciousness with preservation of automatic control. 
The attack may consist of a staggering step or two upon the street; 
of a fall of the hand in writing, to leave a scrawl upon the page; of 
a momentary vacant stare or gaze into vacancy ; of a sudden falling 
asleep with the eyes open (narcolepsy) ; of a sensation of faintness 
or vertigo, with twitchings or convulsions of individual muscles or 
groups of muscles in the face, trunk, or extremities ; or the various 
disturbances which have been described among the aurse. Among 
these conditions are curious psychical disturbances. A patient 
under the observation of the author left his bed in the hospital, ran 
up the track of an inclined plane in the vicinity, jumped from a 
great height to the street below, and was brought back in a mangled 
state. In these states of minor epilepsy crimes may be committed — 
suicide, homicide— without motive and without remorse. Strange 
dual mental states occur. Patients have left home and have been 
found in distant cities or countries, travelling meanwhile without 
mishap. Eccentricities are not infrequent. Incongruities, even in- 
decencies, may be committed. The patient may pass water or pre- 
pare in public for the act of defecation, etc. Between epilepsy and 
insanity, between neurosis and psychosis, it may be impossible to 
draw the line. The disease of the brain may be the cause of both. 
Especially characteristic of epilepsy are dulness with poverty of 
speech, defects of memory, acts of cruelty. These states may occur 
also after the major attacks in the condition of stupor, where the 
mind is still hazy; and periods of maniacal excitement in which 
patients become dangerous are not infrequent, so that proof of the 
existence of epilepsy often suffices in a court of law to secure ex- 
emption from punishment for crime, on the ground of irresponsi- 
bility. The door is open here for much miscarriage of justice. The 
performance of definite acts with the loss of regard of consequences 
is ascribed to the fact that the intellectual centres are held in abey- 
ance, while the lower automatic centres continue to act. Thus an 
architect has been known to walk a scaffolding or gutter at great 
height without losing balance ; a cabman to drive his vehicle through 
crowded streets without accident. Mishaps may occur in these pro- 
cedures. Patients thus affected are liable to pocket things which do 
not belong to them. Gowers speaks of a patient who mistook a 
dinner table, on another occasion the shelves of a cupboard, for a 
staircase. 

Mental degeneration occurs also in certain cases in the inter- 
paroxysmal state, sometimes as loss of memory or control, restless- 
ness, irritability, and perverted morale. The intellect is usually 
unaffected at first, but becomes dull and blunted with successive 
attacks, and with rapidity of degradation in correspondence with the 



748 EPILEPSY. 

frequency and severity of attacks, so that, while in exceptional cases 
epileptics have been distinguished for mental vigor, they drift often 
into dulness and end in imbecility. It may be offered as a consola- 
tion to patients that epilepsy may exist for years or for life, with at- 
tacks frequent and severe, and yet leave the intellect unimpaired. 
It may be repeated that epilepsy and psychosis may have indepen- 
dent as well as common origin, and that the psychosis need not be a 
necessary effect of the epilepsy. Most of the cases of genius said to 
have been affected with epilepsy (Mahomet, Napoleon, etc.) were 
probably only cases of aggravated hysteria. 

Diagnosis. — In marked forms epilepsy may not be mistaken. 
The aura; the cry; the stroke with its loss of consciousness and total 
abolition of motion and sensation; the subsequent convulsions, which 
cease in the course of a few minutes, to leave the patient drowsy and 
dull ; with the complete interval, sufficiently distinguish the disease. 
Enuresis nocturna, ecchymoses of the conjunctiva?, morning head- 
ache or heaviness, may indicate nocturnal attacks. Lighter cases of 
petit mal are often overlooked. They may be usually recognized 
by the arrest of consciousness with the subsequent mental dulness, 
by the existence in certain cases of an aura, and by the condition of 
the interval. The diagnosis may be difficult in childhood, where re- 
flex convulsions are frequent. Time only may clear up certain cases. 
Hysteria may closely simulate epilepsy. The age and sex of the 
patient may be distinguishing points. Epilepsy occurs first most 
frequently in childhood ; hysteria, first at puberty. The attack of 
epilepsy occurs without apparent cause, while hysteria supervenes 
upon some emotional disturbance. The various aurse of epilepsy 
all differ materially from the mental disturbances, palpitation, chok- 
ing sensations, which announce the advent of an attack of hysteria. 
Epilepsy begins suddenly, hysteria gradually. The attack in epi- 
lepsy is often preceded by a cry, which occurs but once ; hysterical 
patients may cry out more or less continuously during an attack. 
The spasms of epilepsy differ from the struggles of hysteria ; they 
are wholly involuntary, irregular, and of very short duration. The 
movements of hysteria are more purposive, more careful of injury 
or exposure. Opisthotonos may be more or less persistent in hys- 
teria, and the convulsions in general are of much longer duration. 
Involuntary discharges, frequent in epilepsy, never occur in hys- 
teria. Loss of the reflexes in the height of the attack is proof of 
epilepsy, but presence of the reflexes does not entirely exclude it. 
Organic disease of the brain (syphilis), uraemia, etc., are separated 
by other signs of these conditions. 

The prognosis regarding life is favorable, regarding recovery is 
unfavorable. The patient may die in a fit. Death occurs more fre- 



EPILEPSY. 749 

quently from accident. The disease has no tendency to spontaneous 
termination. Individual cases may recover. The chances of recov- 
ery become less with advancing age. Recovery is not uncommon in 
childhood, but is rare after puberty. 

Treatment. — Every case of epilepsy must be studied. Sources 
of reflex origin are to be removed. Attention here must be directed 
especially to affections of the stomach and uterus. Irritating cica- 
trices may be excised. Scrupulous attention must be paid to the 
habits of life. Excesses with food, alcohol, must be corrected. Ad- 
dress must be had to the underlying state. Treatment is directed 
to the relief of the attack and prevention of the convulsions. Dur- 
ing the convulsions the patient should be let alone. Only so much 
restraint should be used as to prevent accident from fracture of bone 
or dislocation of joints. A cork, knife handle, may be inserted be- 
tween the teeth to prevent mutilation of the tongue. Clothing 
should be loosened about the body. Attempts to cut the attack 
short with anaesthetics are useless. The subsequent condition of 
the patient is better after a full explosion of the disease. 

In the treatment of the disease proper two remedies assume pro- 
minence, the bromides and atropia. The bromides are best admin- 
istered largely diluted, and in dose and frequency of repetition ac- 
cording to the age of the patient and frequency and severity of the 
disease. Of the various preparations the bromide of potassium is 
the most effective. The remedy is administered in dose varying 
from fifteen to forty grains once or twice a day, preferably in a 
glass of soda water night and morning, increasing up to tolerance. 
Its efficacy may be heightened by administration with some bitter 
infusion, as the infusion of absinthe 3 ij.-iv. per dose. Acne is best 
avoided by the use of arsenic, liquor potassse arsenitis, gtt. ij.-v. 
with each dose of the bromide, and, by frequent washing with soap. 
As a rule the patients do the best who show the least acne. The 
general rule in treatment is to ascertain the smallest dose neces- 
sary to prevent the attacks, and cut the quantity down. The ad- 
ministration of such quantities as produce mental dulness and drow- 
siness is unjustifiable except in the most extreme cases. Each case 
must be studied also in this regard. Attacks which are persistent 
under small, have yielded under large, doses. The remedy must 
be used with regularity for months, sometimes for years. Atropia, 
solution gr. i.- § i., is given in dose of gtt. ij.-v. three or four times 
a day or up to tolerance ; then the quantity is to be reduced and 
kept within these limits. Atropia addresses itself to the underlying 
state. Borax may be tried next, beginning with a small dose, gr. 
v.-xv., and increasing, in the absence of gastro-intestinal irritation, 



750 TUMOR OF THE BRAIN. 

to 3 i.-iss. Borax is best administered with glycerin and syrup of 
orange peel ; thus : 

R Sodii boracis 3 i j . 

Glycerine 3 ij. 

Syrupi am antii corticis § i. 

Salep |iij, 

M. S. Begin with tablespoonful doses. 

Should these remedies fail, resort may be had next to zinc, which 
is best given in the form of the lactate in dose of ten to fifteen 
grains three times a day. With the failure of all these means the 
practitioner may experiment with a host of remedies recommended 
in the materia medica. Cases uncontrolled by the bromides or atro- 
pia are usually unamenable to relief. The knife of the surgeon is a 
derfoier ressort, justified only in cases of threatening degradation of 
the mind. Thus far the results are discouraging. 

TUMOR OF THE BRAIN. 

Tumor of the brain is a growth which, springing from the enve- 
lopes or arising in the substance of the brain, producss a train of 
^^ symptoms according to its situation, 

character, and extent ; most fre- 
quently intense headache, ambly- 
opia or amaurosis, choked disc, ver- 
tigo, vomiting, convulsions, para- 
/ i ''"w^S&^ '•-■s&rtSi lysis °f various cerebral nerves 

t/\ ^yJ> .7. ?Ci ^-ll^i^^^l successively, with or without dis- 
turbance of the intellect. 

The construction and composi- 
tion of tumors vary greatly. Tu- 

of F e^ettaX; U eS tUn '° r0£mWdlel0be berculosis and syphilis are most 

frequent causes. These growths 
spring from the bones or membranes, or develop in the substance 
of the brain. Next ranks glioma (y\ia, glue), a whitish or more 
or less vascular growth, hard or soft in consistence, according to the 
amount of connective tissue, varying in size from a cherry to a fist, 
and situated most frequently in the cerebral hemispheres. Gliomata 
are distinguished, from their composition or combination, as angiec- 
tatic, myxomatous, and sarcomatous, composed respectively of highly 
vascular tissue with tortuous vessels, or of mucous tissue, or abun- 
dant cells and sparse connective tissue. Gliomata are also distin- 
guished by slow growth, liability to haemorrhage, with occasional 
tendency to fatty degeneration and atrophy. Next in the order of 
frequency is the sarcoma, which is again distinguished as the angio- 
sarcoma and myxoma or angio-myxo -sarcoma. Primary card- 






TUMOR OF THE BRAIN. 751 

noma is rare ; secondary (metastatic) is more frequent. Peculiar 
growths, which result from the aggregation of numerous minute, ir- 
regular, shining masses like mother-of-pearl, constitute the choles- 
teatoma, which arises from degenerated epidermic cells arranged 
concentrically about a nucleus. More infrequent is the angioma, 
composed almost entirely of vessels. Still rarer are the fibroma, 
enchondroma, lipoma, and osteoma, terms which indicate the 
character of the growths. Inasmuch as the symptoms of brain 
tumor are wholly due to pressure, distention of vessels and aneurism 
of the cerebral arteries must be included under this head. The arte- 
ries most frequently affected are the basilar and middle cerebral, the 
left more frequently than the right. Among the parasites which 
form growths in the brain are the cysticercus and the echinococcus. 
Etiology. — Certain tumors, the angioma, cholesteatoma, and 
glioma, possibly also fibroma, enchondroma, and lipoma, may be 




Fig. 293.— Gliomata of left hemisphere; asterisk marks site of subcortical growth (Gowers). 

congenital, or at least arise at birth and develop later. Cohnheim 
believed that many cases are survivals from foetal life. Childhood 
offers the largest contingent of cases ; after childhood, the age from 
thirty to sixty; males more frequently than females, in the proportion 
of 3:2. This disproportion exists not only with reference to syph- 
ilis, but to all tumors. Blows upon the head may develop changes 
which are not confined to the bones and membranes, but concern 
also the interior of the brain. This fact, with the more frequent 
abuse of alcohol, accounts for the more frequent affection of the 
male sex. 

Symptoms. — The symptoms of brain tumor are general and 
local. They vary according to the seat rather than the character of 
the lesion, rapidity of growth, etc. Symptoms are immediate and 
remote, according as they result from direct or indirect pressure. 
Tumors in silent regions, as in the hemisphere of either cerebrum 



752 TUMOR OF THE BRAIN. 

or cerebellum, may show no symptoms. So tumors, unsuspected 
in life, have been discovered on autopsy. Small size, slow growth, 
may account for lack of symptoms. Increase in size naturally dis- 
places fluids or blocks vessels, to lead to the accumulation of fluids 
which constitute hydrops in the ventricle, and to lead to the ac- 
cumulation of cerebro-spinal fluid in the sheath of the optic nerve. 
Softening about the tumor develops symptoms of irritation. The 
most frequent of the general symptoms are early fatigue, associated 
often with depression or melancholy, in use of the brain, whether 
for mental or physical labor. The most constant sign is headache, 
intense and persistent. It is felt especially in the region of the fore- 
head, temples, and occiput, though the situation of the pain does 
not necessarily localize the tumor. The headache is often associated 
with vertigo and vomiting — cerebral vomiting, which occurs with- 
out nausea and without reference to food. In the midst of symptoms 
of apparently trivial character convulsions may suddenly supervene. 
They are epileptiform in type, from anaemia the result of reflex spasm 
of the cerebral arteries. Dulness, stupor, retardation of pulse and 
respiration, are evidences of direct pressure upon the brain. Along 
with these symptoms there shows itself, as a rule, the choked disc 
on both sides ; its early occurrence makes it a symptom of much 
value. In these cases the swollen papilla becomes opaque ; its sur- 
face is traversed with dilated arterioles and tortuous veins. It is, 
however, not pathognomonic ; neither the presence nor absence of it 
defines or excludes the disease. 

The tumor acts directly or indirectly in pressure upon indi- 
vidual nerves, or a mass of brain substance to cause hemiplegia. 
The situation of the growth determines the affection of the par- 
ticular nerves. The most frequently affected are the olfactory, 
optic, abducens, and oculo-motor. The facial is usually involved in 
all its branches — a point of value in differential diagnosis. The tri- 
geminal is affected, as a rule, only, or most, in the sensitive 
branches. The hypoglossus, in its narrow bed, is involved on both 
sides. Hemiplegia is sometimes crossed. Electric excitability in 
the affected muscles is usually at first increased and later reduced. 
The reaction of degeneration is rare. Paresis and paralysis are 
much more common than pains and parsesthesise, as pressure de- 
stroys rather than irritates. Tumors in the anterior fossa affect 
especially the olfactory and optic, the first branch of the trigeminus, 
and the oculo-motor nerves. Tumors in the middle fossa affect the 
optic, oculo-motor, and oblique, the abducens and trigeminus. By 
indirect pressure they may produce hemiplegia. Tumors in the pos- 
terior fossa affect the trigeminus, facial, auditory, glosso-pharyn- 
geal, pneumogastric, and spinal accessory. There may be in these 



ABSCESS OF THE BRAIN. 753 

cases tinnitus aurium from irritation of the auditory nerve ; vomit- 
ing and retardation of the pulse from irritation of the pneumogastric 
nerve ; amblyopia from pressure of fluid accumulated in the ven- 
tricles. Tumors in the hemispheres of the cerebrum show local con- 
vulsions, monoplegias or hemiplegias, with ansesthesia and con- 
tractions, amblyopia, aphasia, etc. Tumors of the cerebellum are 
recognized chiefly by the reeling gait, amblyopia, affection of 
hearing and smell, occipital headache, etc. 

The diagnosis rests chiefly upon the tripod, headache, convul- 
sions, and choked disc. It is further established by vertigo and 
vomiting, retardation of pulse and circulation, successive involve- 
ment of cerebral nerves, hemiplegia, etc. 

Treatment. — Therapy has reference only to tumors of syphilitic 
origin. Every case should have the benefit of doubt and be sub- 
jected to radical treatment with mercury and iodine. The most in- 
tense and dangerous symptoms sometimes disappear as by magic 
under the use of the iodides. Large doses are best administered in 
milk, and are most thoroughly conveyed through the body with the 
additional use of mineral waters in quantity. The effect of mercury 
is best secured by inunction. Most frequently the relief which is 
secured is partial and not complete. It must be remembered that, 
though the tumor be dissolved away to leave no trace, irreparable 
damage to the brain has often been done. Other treatment is wholly 
symptomatic. The bromides sometimes suffice to hold headaches 
under entire control. Chloral may relieve insomnia or convulsive 
manifestations, etc. Surgery scores triumphs in this field of 
medicine. 

ABSCESS OF THE BRAIN. 

Suppuration may occur in any part of the brain substance. It is 
most frequent in the cerebrum, next in the cerebellum, and is rare 
in the basal ganglia, the pons and medulla. The temporo-sphenoidal 
lobe suffers most, because of proximity to the ear, disease of which is 
the most frequent cause of abscess. The abscess is single in four- 
fifths of cases. 

Etiology. — The cause of brain abscess may be local or general. 
Nearly three-fourths of cases of abscess of the brain are produced 
by local causes : nearly one-half by diseases of the ear, one-fourth 
by injury. Other local causes are diseases of the nose and caries of 
bones of the skull. The general causes are for the most part metas- 
tases of pyaemia of distant origin. Abscess of the brain occurs at all 
periods of life, but is most frequent in males, in the proportion of 
three to one. 

Morbid Anatomy. — Brain abscesses vary in size from a walnut 
48 



754 ABSCESS OF THE BRAIN. 

to a fist. They are encapsulated in about one-half of the cases. The 
pus is often greenish, and is sometimes fetid. Metastatic abscesses 
are minute and multiple. Abscesses from ear disease and injury 
may occupy a large part of a hemisphere. An abscess may burst 
into the ventricles, or may discharge upon the surface of the brain 
to produce meningitis. 

The symptoms may be latent. Cases have been reported where 
abscesses as large as a. fist, without sign of disease in life, have been 
discovered upon autopsy. Abscesses in the frontal and temporo- 
sphenoidal lobes seldom show signs at first. This is true also of 
abscesses in the great ganglia at the base. Tolerance is established 
in abscesses of slow growth. Again, the disease may be over- 
shadowed by the symptoms of its cause — e.g., disease of the ear, 
trauma, pyaemia. Pyaemia often shows itself with such periodicity 
of fever and sweat as to be mistaken for malaria. The typhoid form 
of pyaemia masks the evidence of brain abscess. Of local signs the 
most common is headache, the situation of which corresponds to the 
seat of the disease more frequently than in tumor. Epileptiform con- 
vulsions are not infrequent. Paralysis develops in correspondence 
with the site of the abscess, but shows itself usually in the form of a 
hemiplegia. Paralysis in the course of, or in connection with, con- 
vulsions indicates abscess more frequently than any other condition. 
Monoplegias are not common. The most frequent monoplegia is 
ptosis. The facial and auditory nerves are affected through the caries 
of ear disease. Optic neuritis, choked disc, occurs, but is not so fre- 
quent as in tumor. Vertigo and vomiting, with staggering gait, 
indicate localization in the cerebellum. DuTness, drowsiness, stupor, 
with progressive wreck of the mental faculties, belong among the 
later symptoms. Patients usually succumb to coma. 

The diagnosis rests especially upon the connection with the 
cause. Evidences of ear disease, trauma, or pyaemia may be found 
in three-fourths of cases. It must be remembered that abscess of the 
brain occurs in the distant course of chronic ear disease. Tumor, a 
far more frequent disease of the brain, develops more slowly and 
advances by progressive paralysis of cranial nerves, and with more 
frequent and intense optic neuritis. 

The prognosis is always grave, but the danger is less immediate 
in cases where the abscess develops slowly and becomes encapsulated. 
Gowers reports cases of abscesses, with calcified walls and inspissated 
contents, latent or quiescent for twenty years. 

Treatment. — The main consideration is prophylaxis, which in- 
cludes especially patient and persistent treatment of ear disease, with 
general asepsis in all cases of trauma, etc. The treatment proper is 
the evacuation of the abscess under the trephine, which the modern 



LOCALIZATION OF LESIONS. 



755 



methods of localization enable the surgeon to accomplish. Unfortu- 
nately final recovery is rare, even with the help of the knife. 



LOCALIZATION OF LESIONS. 

Lesions are localized in the brain by the parts of the body 
affected with symptoms. Though the conclusions are still indefi- 
nite, and the facts of most value to the physiologist and the sur- 
geon, the discovery of motor centres in the brain marks an epoch 
in the history of nervous diseases. The pioneers in this field were 
Hughlings Jackson, who contributed his observations from the 
standpoint of clinical medicine, and Broca, who based his observa- 
tions upon autopsies. Experimental investigations followed later by 
Fritsch and Hitzig, and Ferrier and Horsley. 




Fig. 294. -Cerebral localizations. Outside view. 

Lesions are divided into irritative and destructive. Irritative 
lesions produce spasm and paresthesia; destructive lesions produce 
paralysis and anaesthesia. The field of localization in the brain lies 
in the central convolutions and the paracentral lobule. The cortical 
centres of the hypoglossal and facial nerves, where the coarse motor 
impulses are multiplied or reduced to finer movements, lie in the 
lower third of the anterior central convolution. The centre for the 
arm lies in the middle third of the anterior and part of the posterior 
central convolution. The centre for the leg lies in the upper two- 
thirds of the posterior, upper third of the anterior convolution, and 
the paracentral lobule. The centres of speech are situated in the 
frontal lobes, chiefly of the left hemisphere, lesions of which pro- 



756 



LOCALIZATION OF LESIONS. 



duce aphasia (a, priv., q)a<Ji$, speech). Lesion of the third frontal 
convolution produces ataxic (a, priv., ra^is, order), lesion of the first 
temporal convolution produces amnesic (a, priv., jjivrjais, memory), 
aphasia. More extensive lesions of these centres produce agraphia, 
inability to write, and alexia, inability to read. But anarthria, a 
condition in which the patient is not aphasic at all, but is unable to 
form words or forms them badly, depends upon, and is a most valu- 
able sign of, lesion of the pons. Lesion of the parietal lobe affects the 
muscular sense, so that the patient without the aid of vision loses 
equilibrium. Lesion of the lower portion of the parietal lobe affects 
the conjugated movement of the eyes — that is, irritation intensifies 
the movement and directs the eyes to the seat of lesion, while destruc- 
tion paralyzes it and permits the eyes to rotate in the opposite direc- 
tion. , Lesion of the occipital cortex produces hemianopsia. Disease 
or injury of the internal capsule in its middle portion affects the mus- 




Fig. 235.— Localizations in the cerebrum. Inside view. 

cles of the face and extremities; disease of the posterior portion af- 
fects sensation and produces complete hemiansesthesia. Disease of 
the crura cerebelli produces irritation or paralysis, that is, spastic 
contraction or hemiplegia upon the opposite side, and affects the 
oculo-motor upon the same side, of the body. Disease of the pons 
usually produces crossed paralysis of the body and face — that is, of 
the opposite side of the body and same side of the face. When the 
disease is exceptionally situated in the upper (cerebral) half of the 
pons, above the decussation of the facial fibres, the face is paralyzed 
on the same side as the body. Disease of the corpora quadrigemina 
produces irritation or paralysis of the muscles of the eye. Affection 
of the anterior pair is distinguished by loss of sight and paralysis 
of the pupils; of the posterior pair, by paralysis of the oculo-motor 
nerves, and often by ataxia. Disease of the crura cerebelli may be 



HYSTERIA. 75? 

attended by compulsory movements, especially of rotary character. 
Disease of the cerebellum is marked by vertigo and a staggering 
gait — conditions which have been observed, however, in other lesions 
of the brain. Progressive implication of cranial nerves indicates an 
encroaching lesion, tumor, abscess, etc. 

HYSTERIA. 

Hysteria (varepa, the womb). — A neurosis with symptoms on the 
part of the whole nervous system, distinguished especially by unstable 
nerve centres and loss of control of the will. The term dates from 
ancient times, and had its origin in the belief that the affection was 
due to disease of the uterus. What diseases of this organ occur in 
connection with hysteria are now known to be coincidences or conse- 
quences and not causes. One of the finest chapters in the history of 
medicine was written by Sydenham (Epistolary Dissertation 58) of 
this disease. 

In etiology the most important role is played by sex. Ninety-five 
per cent of the cases are females. When it occurs in males it is most 
frequent in boys. The disease may show itself at any period of life 
from childhood to old age, but occurs with especial frequency about 
the period of puberty. The supreme factors in the production of the 
disease are heredity and training. The disease may be transmitted 
directly, or the hysteria may be the expression of an allied neurosis, 
insanity, epilepsy, migraine, in the ancestry. In our country the 
majority of cases are acquired through defects in education. The 
fault begins with childhood, and rests largely upon the failure to de- 
velop self-control; hence the disease is especially frequent among the 
upper classes, whose luxurious habits lead to indulgence and neglect. 
Diseases of organs, impoverishment of the blood, chlorosis, anemia, 
indoor life, overstimulation at school, aggravate and precipitate at- 
tacks. Outbreaks in later life are generally due to disappointments 
in love affairs or domestic infelicities. 

The disease shows no demonstrable lesion, for, as Sydenham said, 
the case may be considered hysteria only when, after the most care- 
ful examination, all evidence of disease can be excluded. So the 
pathology of the disease rests upon a disturbance of action or func- 
tion which is supposed to be caused by imperceptible, as yet undis- 
coverable, molecular change. 

Symptoms. — The underlying condition is the weak nervous sys- 
tem and the lack of self-control. The disease, as stated, shows symp- 
toms in the whole domain of the nervous system, in which regard it 
is distinguished from hypochondriasis, which confines its manifesta- 
tions to the psychical sphere. Disturbances in this sphere play a 
most important role in hysteria. Hysterical patients are so highly 



758 HYSTERIA. 

irritable as to be sensitive to circumstances and influences unnoticed 
in health. Trifles are exaggerated. The patient yields more and 
more easily, until finally all resistance is surrendered. So the action 
of the higher centres is inhibited. The faculties of the mind revert 
to the uncontrolled, undeveloped, and emotional state of childhood. 
As Sydenham said, "all is caprice." 

Affections of the motor system show themselves especially in the 
form of convulsions and paralyses. The convulsions occur for the 
most part in paroxysms, preceded by some emotional disturbance. 
The immediate outbreak is often preceded or attended by aurse, usu- 
ally on the part of the digestive system, as a sense of' oppression or 
distress in the region of the stomach, singultus, eructations. The 
patient suffers an attack of convulsions which more or less closely 
simulates an epileptic attack. There is rigidity which is often ex- 
treme. Opisthotonos is common and persistent. Spasmodic convul- 
sions supervene, become universal, and are attended with the asso- 
ciate disturbance in circulation and breathing. The difference 
between the epileptic and the hysterical attack rests mainly upon the 
maintenance of consciousness through hysteria. The fall is not pre- 
cipitate as in epilepsy. The patient is careful to select a chair or sofa 
in protection of the body. The tonic and clonic convulsions are more 
violent and much more sustained. The spasms themselves are more 
directly in the line of voluntary movements, and the whole attack 
is protracted into hours or fractions of an hour, far beyond the limits 
of ordinary epilepsy. During all this period, though the eyes are 
wholly or partly closed, the pupils are perfectly natural. Excep- 
tional cases show a closer approximation to epilepsy, sometimes as 
complications — for the diseases do not concur, not even as transition 
stages. As the exact diagnosis is in these cases sometimes difficult 
or impossible, they are often grouped under the term hystero-epi- 
lepsy. They are, however, not epilepsies. They are aggravated 
hysterias. A subvariety of hysteria is offered also in the exagge- 
rated choreic manifestations which constitute chorea magna. These 
cases of wildest gymnastic contortions and half-purposive move- 
ments, with the other vagaries of hysteria, trances, cataleptic states, 
apparent death, make of the victims objects of curiosity and wonder 
with the illiterate, and excite that kind of false sympathy and sen- 
timentality which is fatal to cure. 

While the convulsions of hysteria may involve any of the mus- 
cles of the body, they are wont to affect more especially certain 
muscles, as the muscles of the glottis to produce spasm of the 
glottis, of the pharynx to give rise to the impression of a foreign 
body in the throat, the so-called globus hystericus; and regions thus 
affected have often the reflex sensibility so much diminished as to 



HYSTERIA. 



J 59 



show more or less anaesthesia. So, too, any of the muscles of the 
body, voluntary or involuntary, may be affected with paresis or 
paralysis. But here, too, certain muscles are selected by preference. 
Paralysis of the muscles of the larynx leads to aphonia, of the 
throat to dysphagia, of the intestine to meteorism and constipa- 
tion. The whole limb or half of the body may suffer the same 
paralysis. The paralysis usually affects the leg, and paraplegia is 
much more common than hemiplegia. In all cases the affection is 
rather a paresis than a paralysis. But long- continued paralyses, 




J Epileptcid 



Prcclj'C?nal 




Z Grand Movements 




4 Delirious 



Fig. 296.— Chorea magna. Rhythmical, half -purposive movements of hysteria (Dana). 

often of years 5 duration, may finally bring about permanent lesions, 
atrophic changes, which show themselves in the nerve centres as well 
as in the muscles. A patient in the experience of the author re- 
mained confined to her chair for nineteen years, and finally made 
what recovery was possible under the atrophic changes which had 
supervened. She became able to go about with a stick and crutch. 
Up to the development of serious atrophic change, the reaction of 
degeneration is always absent in hysteria. 

Some form of disturbance of sensation is present in every case. 
Hyperesthesia is more frequent than anaesthesia, and certain sensi- 



760 



HYSTERIA. 



tive points assume prominence in the course of hysteria. Such 
" hysterogenic " spots are points about the head, as if pressed upon 
by some hard, pointed object, as a key, and constitute the so-called 
davits hystericus ; or in the course of the vertebral column, espe- 
cially the region of the ovaries, pressure upon which sometimes calls 
out an explosion, or, per contra, cuts it short in its course. Irra- 
diations from the tender points in the vertebral column constitute 
the so-called cases of "spinal irritation." Anaesthesia may be also 
irregular and slight, or diffuse and extreme. The sensation may be 
diminished or abolished in localized surfaces of the skin or mucous 
i membranes, not infrequently in an entire 

half of the body, to constitute the hemi- 
ancesthesia which is almost peculiar to 
hysteria. 

The contractures usually occur in 
connection with, or immediately sub- 
sequent to, a convulsive attack or ex- 
plosion, and are most frequently located 
in that member or part of the body 
which may be the seat of pain or other 
distress. Concentration of attention 
fixes the seat of disease. Once fixed in 
a member, the contracture persists; and 
though the symptoms of the disease are 
distinguished by their protean charac- 
ter, the deformity assumed in an indi- 
vidual case usually remains with it for 
months, for years, sometimes for life. 
Thus the arm may be contracted in 
fixed flexion, and the contraction of the 
fingers with the included thumb simu- 
lates the late rigidity of hemiplegia. In 
more exceptional cases the fingers are extended to assume the posi- 
tion of tetany. Any attempt to release the spasm intensifies it, and 
increased flexion of the wrist, which loosens to some extent the rigid- 
ity of hemiplegia, only exaggerates that of hysteria. The leg, on 
the other hand, is fixed in extension with the heel, drawn up to bring 
the foot with its inverted sole and flexed toes in a straight line with 
the leg. In any case hysterical contractures, though of years' dura- 
tion, may disappear under the influence of powerful emotion. These 
are the cases upon which miracles are worked, and the triumphs of 
the faith cure are recorded in this field. A similar spasm of the dia- 
phragm, with relaxation of the muscles of the abdominal wall, pro- 
duces, with the accumulation of gas in the intestine, that distention 




Fig. 29?.— Hysterical contracture of 
right leg and foot (Charcot), 



HYSTERIA. 761 

of the abdomen which is known as the phantom tumor. Hence 
this tumor disappears entirely under anaesthesia. 

Among vaso-motor disturbances may be noticed increase in the 
secretion of tears, saliva, sweat, which may be localized or unilate- 
ral. Even the flow of milk may be increased. The secretion of 
urine is often enormous. Such urine is, Sydenham says, " clear as 
water from a rock." More peculiar is the discharge of blood which 
may take place from the mucous membranes — that is, from the 
mouth, the intestine, the lungs. More incredible are the subcuta- 
neous haemorrhages and free discharges of blood upon the surface 
which constitute stigmata. Localization of these stigmata in the 
hands and at the ankles in states of religious ecstasy has been cred- 
ibly reported. These cases, however, are usually regarded with sus- 
picion, as most of the haemorrhages are aided by voluntary breaks 
of the surface. The exact stigmata of crucifixion are always arti- 
ficial, and real haemorrhage of the lungs belongs to disease, especially 
to tuberculosis, which intensifies, if it does not develop, the hysteria. 
Pretty much all the cases of so-called vicarious menstruation belong 
to tuberculosis, the disease par excellence which disturbs the menses. 
Many cases of haemorrhage, ''bleeding from the lungs," are really 
bleedings from the gums, and blood shown in vessels has been found 
to have been derived from an outside source. See also chapter on 
Haemorrhagic Diathesis. 

Hysteria is in its nature full of freaks, some of which — catalep- 
tic, clairvoyant, lethargic states, transfer of sensation from one limb 
to another by the application of a piece of metal — remain as yet in- 
capable of explanation. It must be remembered that hysteria is a 
near neighbor to insanity, and that the explosions of the disease are 
states of temporary insanity. A grave complication is that excessive 
derangement of digestion which is shown in obstinate vomiting 
and anorexia. " Fasting girls " are nearly all hysterical. In many 
of these cases there may be detected an element of fraud. Hidden 
food is swallowed on the sly. Individual cases are real, and these 
cases may be always distinguished by the progressive loss of weight 
which necessarily ensues upon the deprivation of food. In the expe- 
rience of the author a case of this kind, attended with vomiting of 
blood, was presented to the class as a gastric ulcer. The patient ac- 
tually died of starvation, and the most careful post-mortem exami- 
nation failed to disclose any lesion whatever. 

Affections of the bladder are not at all infrequent, sometimes as 
dysuria with frequent desire of micturition, more frequently as 
anuria, which may last a long time, a week or ten days, without 
evidence of uraemia — an important point in differential diagnosis. 
When catheterization is actually necessary in these cases it should 
be done by the nurse. 



762 HYSTERIA. 

The diagnosis rests upon the sex, age, and history of the indi- 
vidual, though negative testimony in any of these particulars does 
not necessarily exclude the disease. The train of symptoms is too 
irregular to be associated with organic disease. The influence 
of the emotions may be distinctly observed. Examination by the 
physician intensifies the symptoms. The convulsive seizure is dis- 
tinguished by the preservation of consciousness, the rhythmical, half- 
purposive movements, the condition of the pupil, which responds to 
light, the long duration of the attack. The contracture and paraly- 
sis are differentiated by their associations. Paraplegia, for instance, 
is almost never hysterical. Affection of one vocal cord is unknown 
in hysteria. Hysterical paralysis of the larynx is double. It is as 
easy to recite rules in diagnosis as to multiply words in the descrip- 
tion of symptoms. They are often alike vain. The most experi- 
enced practitioner, in the face of lessons which may be still fresh in 
the memory, is liable to be deceived by the freaks of hysteria. 

Prognosis. — Hysteria is always a chronic affection. The under- 
lying condition is born with the individual and remains lifelong. 
The disease may, as stated, actually take life. Death has occurred 
in an attack of convulsions, more frequently in cases on the border 
lines of epilepsy. Exceptional cases succumb to spasm of the glot- 
tis, more frequent cases to vomiting and marasmus. Individual 
cases recover, sometimes absolutely, more frequently incompletely 
with liability to relapse. Bad cases may terminate in insanity, es- 
pecially in melancholia, religious fanaticism, finally in dementia. 
Psychoses, which supervene at the grand climacteric, have a bad 
prognosis. 

Treatment is difficult. It is usually a matter of morale. In no 
field of medicine is interference so often meddlesome and injurious. 
This is especially true in the domain of gynaecology. The manage- 
ment of a case of hysteria calls out the tact of the physician. He 
must steer between sympathy and indifference. In the treatment of 
exaggerated cases isolation, especially with a reliable, preferably 
a stolid or phlegmatic nurse, is a sine qua non. The patient is to 
be fed, and the food is to be digested and absorbed. The way out is 
through food and sleep — i.e., nutrition and rest. It is well to re- 
member a French proverb, " Qui dort, dine" — who sleeps, dines. 
Regarding drugs, the less the better. Opiates should certainly be 
avoided. The convulsions of hysteria are so quickly allayed by 
chloral as to make the use of it a constant temptation; here, too, 
the less the better. Convulsions usually subside so soon as the phy- 
sician is left alone in the room with the patient, who quickly learns 
that he understands the case. Nervous states may be relieved by 
the bromides, asafoetida, and valerian, but here, too, the less the 



HYPOCHONDRIASIS. 7(53 

better. To treat the individual rather than the disease is the sum of 
therapy. 

HYPOCHONDRIASIS. 

Hypochondriasis {vno, under, jortfpoV, cartilage). — A psychosis 
characterized by a concentration of the mind upon the internal or- 
gans. With hysteria, it is an almost wholly psychical condition, but 
with an entirely different expression. Hysteria is largely a loss of 
control of the will ; the hypochondriac may be a person of strong 
will. Males predominate, bat there are hypochondriac females as 
well as hysterical males. The conditions may be associate. Hypo- 
chondriasis usually rests upon some slight disturbance in the sen- 
sory sphere, a hypersesthesia or paresthesia, which passes unno- 
ticed in health, but forms the basis of an imaginary malady in this 
disease. The affection is located, in the great majority of cases, as 
the name implies, under the cartilages of the ribs, in the liver or 
other organ of the abdomen, and is the exaggeration of sensations 
caused by dj'spepsia, flatulence, haemorrhoids, etc. A slight lesion 
of the mucous mein^rane is mistaken for syphilis, and the patient 
is often a lifelong victim of syphilophobia. Impotence, which the 
patient may really induce by the fear of it, is considered a sign of 
organic disease of the spinal cord, locomotor ataxia, etc. Palpita- 
tion of the heart, a common expression of gastric catarrh, is re- 
garded as a sign of heart disease which may cause sudden death at 
any time. Flatulence indicates the existence of a tapeworm which 
is consuming the vitality of the body. The fear of cholera, in the 
presence of an epidemic, may be so great as to make the patient 
sweat with anxiety and actually produce a diarrhoea. The suffer- 
ings of the hypochondriac are intensified and prolonged by perusal 
of medical works, or more especially of popular medical literature, 
which can convey only erroneous ideas. The hypochondriac de- 
lights to dwell upon his symptoms with a fellow-sufferer or with 
any one whose attention he can secure. He gloats over details with 
downcast eyes, and is finally shunned like a plague by those who 
know him. The confirmed hypochondriac, with his constant fear of 
death, and extraordinary care of himself at the expense of every 
one else, will wear out and survive every member of his family. 

The treatment is an arduous task, for the disease, as in hysteria, 
depends often upon inherited states. The physician must not ignore 
and must not emphasize individual symptoms. Especial attention 
must be paid to the constipation which is almost always present. A 
course at a watering place best relieves all the symptoms. As a rule 
the bitter are better than the saline laxatives. Among them the phy- 
sician may select the aromatic tincture of rhubarb, 3 i. ter die ; the 



764 NEURASTHENIA. 

compound pill of rhubarb, one or two after each meal ; a pill of 
podophyllin, gr. J-J at bedtime ; a pill of aloes, belladonna, and 
strychnia ; or the compound licorice powder, one or two teaspoon- 
fuls once or twice a day. Sedatives and hypnotics, bromides, chlo- 
ral, etc. , do more harm than good, but acids, especially hydrochloric 
acid gtt. xx. well diluted ter die ; tonics, tinctura nucis vomicae 
gtt. xx. ; or strychnine nitrate gr. ¥ y~ 2V ter die, brace the stomach 
and the nervous system. Alcohol is bad as a rule. It disturbs di- 
gestion. In the subsequent reaction it leads to melancholy. The 
management of hypochondriasis is a matter of tact, of savoir-faire, 
of knowledge of the race and of the individual man. 

NEURASTHENIA. 

Neurasthenia (vevpov, nerve, daBevsia, weakness) is an exhaus- 
tion of the nerve centres, especially observed among individuals who 
have inherited weakness from some weak, perhaps remote, ancestor, 
or whose lives of continuous occupation, strain, and competition 
leave no time for rest. Neurasthenia is a disease of the railroad, 
telegraph, and telephone life of our modern civilization. The condi- 
tion is aggravated by the use of remedies to stimulate strength and 
enforce sleep — alcohol and morphia — and by sexual abuse and ex- 
cess. Forms are distinguished as cerebral, spinal, and universal 
(Beard), and in these distinctions the transition lines between this 
affection and hysteria, hypochondriasis, and melancholia cannot al- 
ways be strictly drawn. Spinal neurasthenia is very apt to include 
organic disease of the spinal cord, myelitis, tabes, or other scleroses. 

Symptoms. — Neurasthenia expresses itself especially in early 
fatigue, lack of concentration, loss of originality, incapacity of 
effort, headache, pain in the back of the neck, irritability of 
disposition, more or less constant anxiety and apprehension. 
Favorite expressions of fear are agoraphobia, fear in open places ; 
claustrophobia, fear in closed places ; monophobia, fear of being 
alone ; anthropophobia, fear of human beings ; siderophobia, fear of 
lightning ; mysophobia, fear of dirt ; pantophobia, fear of every- 
thing. These conditions may be the expression of other diseases or 
of mere nervousness, and may be entirely absent in cases of pure 
neurasthenia. Most cases show disturbances of digestion, with 
dyspepsia and vertigo, sometimes with gastralgia. Insomnia is a 
prominent symptom. The patient tosses about in bed sleepless for 
hours, and awakens in the morning unrefreshed. Finally he forces 
sleep with hypnotics and thus further undermines the nerve cen- 
tres. Various parsesthesise, hypersesthesiaB, and hyperalgesise occur 
in the course of these cases. Localized sensations in the spinal 
column constitute the obstinate symptom known as spinal irrita- 



CHOREA. 765 

tion. The heart's action is disturbed in various ways. Palpitation 
is common, with arhythmia and precordial anxiety. Onanism and 
impotence occur as both cause and effect in cases of neurasthenia. 
Sensations of coldness, numbness, formication, flushing of the face 
or pallor, cyanosis, tachycardia, sweatings, spermatorrhoea, vary the 
scene in the symptomatology of neurasthenia. 

Prophylaxis is the adoption of the rule laid down by the great 
philosopher Kant : Eight hours work, eight hours recreation, eight 
hours sleep. Unfortunately modern civilization does not accept 
these rules, and ' ' success " in life can rarely be reached in this way. 

Treatment is rest ; all other remedies are secondary and subor- 
dinate. The difficulty is to secure rest. Idleness, stagnation, is not 
always rest. In stagnation set in at once the intensely active pro- 
cesses of decomposition. In certain cases isolation is a necessity. 
Travelling is always a diversion. A sea voyage, with its inanities, 
secures at least absolute rest. The moving panorama observed from 
the window of a railroad car furnishes diversion as well as rest. A 
stay of a few weeks at a watering place, with its change of scene and 
association, may secure the desired effect. Hydrotherapy, in the 
form of frequent warm baths with gentle friction, is often of value. 
General electrization according to the method of Beard, the negative 
pole at the feet and the positive stroked over the body with the roller, 
refreshes, strengthens, and tranquillizes in the course of time. Drugs 
are to be avoided as much as possible, yet occasional doses of sul- 
phonal, paraldehyde, or even of chloral may be required. Food 
should be administered regularly, and remedies — hydrochloric acid, 
mix vomica, orexin — may be given to secure its digestion. 

Babes, of Bucharest, injected nerve substance itself subcuta- 
neously, fifteen to seventy-five grains per day in bouillon, into seve- 
ral patients affected with neurasthenia, with satisfactory results. 
Similar experiments have also been made with epilepsy and tabes. 
The operation must be done with every precaution of antisepsis. 
The good results, like those obtained after the injection of the juice 
of the testicle of young dogs, are chiefly, if not wholly, due to sug- 
gestion, a remedy of more value in nervous diseases than in any 
other affection. 

CHOREA. 

Chorea (xopeia, dance), St. Vitus' dance, is a neurosis of child- 
hood, characterized by more or less continuous spasmodic move- 
ments, with inco- ordination ; aggravated by voluntary motion, ar- 
rested only in profound sleep ; associated usually with some, if only 
slight, impairment of the mind and more or less paresis. 

The disease exists in two forms, chorea major and minor, and 



766 CHOREA. 

prevailed as an epidemic, as chorea major — the " dancing mania" — 
in the middle ages. Chorea major, from which the disease is named, 
is a subvariety of hysteria, and, with other forms of that disease, is 
rapidly spread by imitation. The victims of this affection were sup- 
posed to be cured at the chapel dedicated. to St. Vitus, hence St. 
Vitus' disease. Chorea minor, the true chorea, Sydenham's chorea, 
here described, though it rests upon no discoverable constant lesion, 
stands in no direct relation with hysteria. 

Etiology. — Chorea is three times as frequent in girls as in boys. 
Nearly half the cases occur between the ages of ten and fifteen, 
four-fifths between five and fifteen years. The disease grows more 
rare with advancing age, and cases which occur in extreme age are 
usually symptoms of some definite disease of the brain. Pregnancy 
sometimes causes chorea, which distinguishes itself from that of 
other cause by its liability to recurrence with subsequent preg- 
nancies. It is most frequent during the first pregnancy, and almost 
never occurs for the first time after the age of twenty-five years. It 
may show itself at any time in pregnancy, but is most frequent in 
the third month. Recurrent attacks in subsequent pregnancies occur 
at any time. 

Chorea is sometimes precipitated or caused by fright, in which 
case it supervenes rapidly — as a rule in less than a week. Cases of 
long interval have a different origin. The relation to rheumatism is 
more distinct, as fully one-fourth of all cases occur in the course 
of, or subsequent to, rheumatism. In a majority of these cases the 
chorea is evidently due to heart disease of rheumatic origin, and 
the sequence runs : acute rheumatism, valvular disease of the heart, 
chorea. In this connection the chorea may depend upon organic 
lesion of the brain — e.g., emboli in the capillaries of the brain, 
a condition which has actually been demonstrated in certain cases. 
The actual existence of valvular disease does not necessarily imply 
this condition, as the chorea may be, and is in the vast majority 
of cases, due to the same cause which produced the rheumatism and 
heart disease. In other words, chorea is probably the expression 
of an infection, of defective innervation due to the action of a 
toxine. The more or less definite duration of the disease, and the 
exemption secured by single attack, speak in favor of this view. 
The preference of youth, and the occurrence during pregnancy, 
which often liberates toxines, are additional points in support of the 
infection theory. The fact, however, that chorea supervenes in con- 
sequence of mental emotions or impressions, especially fright, imi- 
tation, after trauma, proves that not all cases have this origin. 
Various organic diseases of the brain (tumors, degenerative lesions 
left by apoplexy, epilepsy, etc.) may be followed by chorea. These 



CHOREA. 767 

cases of traumatic post-apoplectic or post-epileptic attacks constitute 
the cases of so-called symptomatic chorea. 

Chorea is, therefore, no single process ; it may be a pure neurosis, 
it may be symptomatic, or it may be an infection. The pure chorea 
of childhood, whether or not it occurs in the course of rheumatism, 
is probably, in the vast majority of cases, due to the same infection. 

The disease may or may not have a morbid anatomy. Even the 
cases dependent upon organic diseases show no constant lesion. The 
conditions actually discovered are the expressions of defective nu- 
trition, as badly nourished arteries, dilated vessels, exudations in 
lymph spaces, along with degenerative lesions. Many cases show 
no lesion whatever. 

Symptoms. — The disease usually develops insidiously. There is 
noticed at first some disturbance in the disposition : the child be- 
comes melancholy, irritable, or morose ; it loses the capacity of men- 
tal effort, and is often punished at school for lack of attention, 
stupidity, or for get fulness. It soon becomes restless ; it cannot 
sit still, loses appetite, becomes constipated, and finds it difficult to 
fall asleep. The inco-ordinate movement of muscle is usually first 
shown in the face as a quick grimace, a sudden twitching of the 
mouth or wink of the eye. The voluntary movements show soon 
a certain awkwardness : water is spilled from a glass in the act of 
drinking, or food from the spoon or fork in the act of eating ; the 
arm is suddenly jerked at the side, sometimes with some contortion 
of the body, to give the appearance of sulkiness. Soon the move- 
ments become more continuous and more universal ; the leg jerks 
as well as the arm, the face twitches more or less continuously, and 
the whole body moves irregularly. This condition, which shows 
itself at rest, is very much intensified by voluntary motion, oris 
especially marked as the child becomes conscious of observation. 
The disease continues to spread over the body, until finally all the 
voluntary muscles are involved, including the tongue, larynx, and 
diaphragm. Except in the worse cases, the involuntary muscles 
are unaffected. There is no difficulty in swallowing. The bowels 
and bladder are perfectly normal. The muscles first affected are 
usually worse affected. The disease always shows its main expres- 
sion in the face, and, inasmuch as it is associated with some mental 
impairment, it shows a peculiar physiognomy. At perfect rest the 
expression is listless, sullen, and dull, but the rapid play of indi- 
vidual muscles distorts the expression in every way. The face has 
the appearance of a mask, whose monotony is played upon by elec- 
tric shocks, and changed from melancholy to mockery, from sur- 
prise to a sardonic grin. The voice, too, is broken, and changes in 
its tones in the same sentence. In bad cases the patient is unable to 



768 CHOREA. 

tvcdk, being tripped by his own legs. In extreme cases he may find 
no rest in a chair, or even in bed, out of which he may be con- 
vulsively thrown. In all cases the disease is more marked on one 
side, usually the left. Where the predominance is extreme the case 
is known as hemichorea. 

Electric irritability is unaffected or but slightly increased. The 
disease is unattended with pains or paresthesia? ; the sensitive 
nerves are unaffected, or, if affected at all, are somewhat hyper- 
sesthetic ; the reflexes are normal. Notwithstanding the incessant 
working of the muscles, there is no feeling of fatigue. Choreic 
patients are, however, never so strong as in health. The appetite 
may remain good, the bowels regular. Nutrition suffers at first 
from loss of sleep ; later there is pallor from ansemia, which may 
lead to marasmus. The pupils are usually slightly dilated. The 
mental faculties in mild cases are somewhat dulled; in marked 
cases the dulness may increase to actual dementia, with involuntary 
discharges from mental apathy. In nervous women, in connection 
with puberty or pregnancy, the nervous affection may take the form of 
excitement with delusions or mania. This so-called maniacal chorea 
gives place in the course of a few weeks to dulness and listlessness. 

Course and Complications. — The disease lasts for weeks, on an 
average from six to twelve weeks. It may terminate in three 
weeks or continue for six to twelve months. Usually in these pro- 
tracted cases there are remissions of longer or shorter duration. Re- 
lapse and recurrence are frequent. A second attack occurs in one- 
third of cases. Instances are recorded of nine separate attacks. The 
occurrence of fever belongs to complications, especially to rheuma- 
tism or endocarditis. The pulse is usually frequent, and is often ir- 
regular in correspondence with the action of the heart, auscultation 
of which may disclose a systolic murmur at the base or actual val- 
vular lesion. Embolus, hemiplegia, or softening of the brain may 
occur in consequence of the lesion of the valves. Ulcerative endo- 
carditis in connection with chorea is almost unknown. 

The prognosis is favorable, especially in children, but assumes 
some gravity with advancing age. Pregnancy aggravates the mor- 
tality, at times to twenty-five per cent. Patients usually recover ab- 
solutely ; exceptional cases are followed by psychoses or paralysis. 

The diagnosis is usually easy. The irregular, spasmodic, bizarre 
movements of recent and rapid onset, with the peculiar physiog- 
noni}', readily distinguish the disease. 

Forms. — Chorea is sometimes closely connected with hysteria. 

Hysterical chorea is often the result of imitation; the movements 
are more regular and rhythmic. They are also less violent than 
cases of true chorea. 



CHOREA. 769 

Adult chorea occurs at any period of life, even up to advanced 
age, and more distinctly in connection with heredity. Peretti re- 
cords a case where twelve descendants of a choreic woman were 
attacked with the disease in the second half of life. Adult or here- 
ditary chorea is unassociated with heart disease. It is more common 
in men than women, and is especially distinguished by the fact that 
the movements are more distinctly under the control of the will. 

Electrical chorea (Bergeron) is distinguished by the sudden, 
shock-like twitchings of muscles, like those under electricity. The}" 
are aggravated by emotion or efforts at control. Electrical chorea 
shows no other symptom, and these almost invariably disappear. A 
peculiar variety of this affection is seen in Lombardy, where it is 
known as Dubinins disease. The attacks leave, in the course of 
months, paresis and paralysis, and are sometimes attended with uni- 
lateral epileptiform convulsions. The disease is supposed to have 
its seat in the cerebral cortex. 

Chorea major is really, as stated, a subvariety of hysteria. The 
movements are more co-ordinate and are much more distinctly pur- 
posive. The conscious convulsions and the exaggerated freaks of 
hysteria, circular movements, dancing manias, gymnastics, climbing 
of bedposts, etc., belong to this form of disease (see page 758). 

Treatment. — The mode of life is to be regulated. The patient 
should be kept quiet, must be removed from school. Evidence of 
caprice, apparent wilfulness, or obstinacy should be allowed to pass 
unobserved. Peace of mind is best secured by quiet. The most 
valuable remedy is sleep, under which the convulsive movements 
cease and the nervous system rests. Sleep is best secured by warm 
baths at bedtime or frequently during the day. They may be re- 
peated as often as every hour. Aggravated cases require the use of 
chloral, which in small doses, gr. ijss.-v.-x., with peppermint water 
3i.-3ss., usually suffices. Chloral is better than any other hyp- 
notic, though sulphonal, trional, and paraldehyde have individual 
advocates. Arsenic may be regarded as a specific in a case of pure 
chorea — evidence again of the infectious origin or nature of the dis- 
ease. The remedy should be given in small dose and gradually 
pushed to tolerance. No form is better than Fowler's solution, which 
may be increased from the dose of one or two to ten or fifteen drops 
three times a day after meals. Irritant effects, pain, diarrhoea, may 
be avoided by the administration at the same time of a few drops of 
tincture of opium. The disease is in this way usually cut short one- 
half or one-third its natural duration. Rheumatic complications call 
for the use of the salicylates. Faradization and massage assist in 
supporting the nutrition of the muscles. Iron, strychnia, and hypo- 
phosphites are the best general tonics in the way of drugs. Food 
49 



770 PARALYSIS AGITANS. 

and fresh air are absolute essentials throughout the whole course of 
the disease. 

PARALYSIS AGITANS. 

Paralysis agitans; shaking palsy. — A peculiar paresis, attended by 
tremors of individual members or of the whole body, Which tremors 
may be suppressed for a time by act of the will, ceasing altogether 
or becoming feebler in sleep ; normal electro-motor and reflex ex- 
citability ; inclination of the body forward. 

History. — Paralysis agitans was first described as a separate dis- 
ease by Parkinson (1817), who distinguished it from chorea and other 
tremors. Parkinson's brief but graphic account excited, however, 
but little attention, and the character of the disease was only fully 
appreciated after the descriptions of Marshall Hall, Stokes, and Todd 
in England, Romberg in Germany, and Trousseau in France (1840- 
1860). Charcot (1867) separated the disease from multiple or dis- 
seminated sclerosis. 

Etiology. — In comparison with other neuroses the disease is rare 




Fig. 298.— Position of the hand (pill-rolling) in paralysis agitans (Charcot). 

and belongs to advanced life. Males are affected more frequently 
than females, in the proportion of five to three. It is more common 
in the lower walks of life. The role of heredity is insignificant. It 
has followed in the course of acute infections, more distinctly af- 
ter trauma, and more frequently after psychical distress, as after 
fright. 

Pure paralysis agitans is no longer a neurosis. It has now a dis- 
tinct morbid anatomy. Ketscher found abundant degenerative 
changes in the brain and cord in three cases, and identified them 
with the changes in ten cases which occur in old age. Paralysis 
agitans is, therefore, in reality a premature senescence. 

Symptoms. — The disease develops slowly. The onset may be 
more rapid when the affection follows fright. The symptoms are 
noticed first in the upper extremity, more frequently in the right 
than in the left. The hand loses its cunning. The first loss is no- 
ticed in the finer movements, as in writing, drawing, etc. Associ- 
ated with the weakness, preceding it in the majority of cases, is the 



PARALYSIS AGITANS. 771 

tremor. It begins in the hand, in the thumb and index finger, 
sometimes in the shoulder, and gradually extends, most frequently 
in the order of hemiplegia — that is, from arm to leg on the same side. 
In exceptional case this course may be interrupted. Thus, it is not 
so regular when the disease begins in the lower extremity. A 
common beginning: is that agitation of the thumb and forefinger as 
if rolling a small body, a pill. In the leg the tremor is most marked 
in the foot. In sitting the heel may beat a tattoo upon the floor. 
Though the muscles of the back may be affected, the muscles of the 
abdomen escape. The head is not affected, though it may be indi- 
rectly agitated by movements of the trunk. The face is very rarely 
involved. The tremor is distinguished from that of other or allied 
affections by its persistence during rest. The motion is continu- 




Fig. 299.— Attitude and gait in paralysis agitans (Dana). 

ous ; the hands move upon the knees. It is arrested for a time 
by volitional effort, but renews itself and attends its continuance. 
Efforts to control it, at first successful, intensify it later. It is first 
recognized in the handwriting. The letters are distinct, but the 
lines are zigzag. Fine variations may be recognized by the lens. 
Stiffness sets in later to limit movements of various members. So 
the head may be fixed upon the breast, the arms flexed, the fingers 
deformed as in arthritis deformans, the feet brought to the condition 
of varo-equinus. The whole body is bent forward as in running. 
The step is short, quick, and tumbling. The expression is impas- 
sive. Extreme cases may be reduced to forced movements forward 
or backward. Sleep stops the tremors at first. Electric reaction is 
normal. The reflexes are undisturbed. There is usually more or 
less emotional disturbance, melancholy, from loss of power. Tactile 



772 MULTIPLE SCLEROSIS. 

sensation remains unaffected, that of temperature is disturbed, in 
three-fourths of the cases. Victims of shaking palsy suffer ivitli 
heat. They cannot bear cover even in cold weather. Aside from 
the melancholy mentioned, the intellect is undisturbed. Exceptional 
cases show mental failures, convulsions, cramps in the legs, etc. — 
symptoms probably due to organic complication. > 

The disease is as slow in progress as in onset. It may last for 
decades, but usually cuts life short through its remoter effects, as 
want of exercise, bed sores, with sepsis, gradual marasmus, etc. 

The diagnosis is established by the age of the patient, by the 
peculiar habitus, continual rhythmical movements arrested only 
in sleep, with the persistence of the reflexes and electric reactions. 
Paralysis agitans is differentiated from multiple sclerosis by the facts 
that (1) sclerosis occurs before forty ; (2) the movements, in paralysis 
agitans arrested or reduced, are in sclerosis intensified by volitional 
efforts ; (3) paralysis precedes the tremor in sclerosis, and, as a rule, 
follows it in paralysis agitans ; (4) sclerosis affects the head and shows 
nystagmus, conditions which do not occur in paralysis agitans ; 
(5) the words are disarticulated in sclerosis, and are rather run to- 
gether in paralysis agitans, which shows also the piping voice 
(Shakspere's childish treble) commonly, but very erroneously, as- 
cribed to age ; (6) paralysis agitans usually shows itself first in the 
upper, sclerosis in the lower, extremity. 

The tremor of age is distinguished by its more universal dis- 
semination and early implication of the face. Toxic tremor, as after 
mercury, lead, etc., is distinguished by the presence of toxic signs. 

Prognosis. — Paralysis agitans is incurable. It may be relieved 
or temporarily retarded. It is unattended with immediate danger to 
life. 

The treatment calls for rest, relief of anxiety and fatigue. Elec- 
tricity is of little or no value. Nerve stretching is dangerous. The 
only remedy which merits the name is arsenic, which produces its 
best effect when used subcutaneously. The liquor potassse arsenitis 
is diluted with twice as much water and injected under the skin of 
the back. The dose, small at first, should be gradually increased 
to tolerance. Anodynes, which may be demanded in extreme cases, 
should be used with caution and selected with care. Indian hemp 
more especially hyoscy amine gr. yio-Toir^ is to be preferred to opium. 



MULTIPLE SCLEROSIS. 

A disease caused by the development of scleroses throughout the 
brain and cord, characterized by tremor, evoked or exaggerated by 
effort, scanning speech, nystagmus, pareses in various muscles ; 



MULTIPLE SCLEROSIS. 773 

often with contractures, increased reflexes, preservation of sensation; 
occasionally by amaurosis, apoplectiform attacks, and delirium. 

History. — The disease is of modern recognition, and, though 
observed by Carswell and Cruveilhier and described by Frerichs, was 
especially set apart and distinguished by Vulpian and Charcot, who 
isolated cerebral, spinal, and cerebro-spinal cases according to the 
seat of the disease. In most cases the process is disseminated, and 
consists of islets of sclerotic tissue scattered through the substance 
of the brain and cord. 

Etiology. — Heredity- is insignificant; sexes show no difference; 
age is of most moment. The majority of cases occur between twenty 
and thirty-five; exceptional cases have been recorded as early as 
seven and as late as sixty years. The disease has followed appa- 
rently in consequence of trauma, the infections — typhoid fever, 
small-pox, diphtheria, and erysipelas — and in the course of preg- 
nancy after exposure to cold, after severe mental and bodily strains, 
etc. It has developed in the course of a year after recovery from 
myelitis or other acute affection. In a case under observation of the 
author at the time of this writing, the sequence ran: hemorrhage in 
the cord after violent effort; myelitis with paralysis of the bladder 
and bowels; at the end of a year volitional tremor, scanning speech, 
nystagmus, and spastic contraction of the lower extremities. 

Morbid Anatomy. — The disease consists, in essence, of depots of 
condensed tissue, varying in size from the barely visible to masses 
of the diameter of ten centimetres or more. These masses are indu- 
rated, sometimes elevated, sometimes sunken, gray or white, smooth 
or lustrous. They are seen to consist, under the microscope, of 
hyperplastic connective tissue. The nerve tissue proper is shrunken 
and wasted. The vessel walls show hyaline degeneration with vari- 
cosities. The white substance is .shrunken to a narrow ring about 
the axis cjdinder, which persists for a time and finally disappears. 

Symptoms. — The symptoms of multiple sclerosis are said to be 
kaleidoscopic; they var}' according to the seat of the disease. The 
onset is insidious, seldom sudden, and is distinguished, when it 
begins in the brain, by headache, vertigo, and psychical distress. 
Oases of more sudden onset simulate attacks of apoplexy. Begin- 
ning in the cord, the disease shows itself first in lack of co-ordina- 
tion, early fatigue, tremor. The tremor is first noticed in the 
arms; it extends to involve the lower extremities, and in the prog- 
ress of the disease does not spare the face. The tremor is peculiar 
and characteristic. It is at first absent at rest, and shoivs itself only 
on movement. Later it is more continuous, but is always more in- 
tense in efforts of the will, or under observation or emotional dis- 
turbance. The more the patient tries to control the movements the 



774 DEMENTIA PARALYTICA. 

more uncontrollable they become. The movements become wild and 
irregular; the patient spills water in an attempt to take a drink. 
The disease is hereby distinguished from paralysis agitans, in which 
tremor or movement is arrested or inhibited by efforts of the will. 
As a modification of this tremor is the alteration of speech, which 
consists in the disarticulation of words in syllables expressed in 
monotones. The effect is that of scanning. Speech is often inter- 
rupted also by sudden inspiration, hiccough, etc. 

Spastic contractions are more frequent in the lower extremities. 
Patients sometimes present the appearance of cases of lateral sclero- 
sis. The reflexes remain unaffected or are later intensified. Various 
parsesthesiee occur in individual cases. Nystagmus is often asso- 
ciated with impairment of vision, as the tremor of the whole body is 
later, followed by paresis. The disease is slow in its progress, and is 
more or less progressive, with periods of apparent arrest or sudden 
aggravation. Attacks of vertigo are frequent in all stages of the 
disease. Attacks of apoplexy occur in about twenty per cent of 
cases. A sudden coma, with elevation of temperature, is followed 
by hemiplegia or by intensification of all the symptoms. 

The diagnosis rests upon the tripod formed by the prominent 
symptoms — volitional tremor, scanning speech, and nystagmus. 
These symptoms, in association with the preservation of sensation 
and escape of the bladder and bowels, distinguish the disease in most 
cases. It must be remembered, as stated, that the picture varies 
with the site of the lesion. The disease lasts two to twenty years, 
on the average five to ten years. Death results from apoplexy, cys- 
titis, decubitus, marasmus. 

Treatment is of little value. Warm baths are beneficial in stay- 
ing the progress of the disease. Cold of all kinds is injurious. Re- 
garding exercise, it is difficult to draw the lines to avoid the Scylla of 
fatigue and the Charybdis of degeneration from disuse. Electricity 
in all forms seems to be useless. Arsenic has recommendations. It 
is customary to prescribe arsenic in doses of three to five drops three 
times a day. 

DEMENTIA PARALYTICA. 

Dementia (de, privative, mens, mind) paralytica (a much finer 
designation than its synonyms, progressive paralysis of the insane 
or general sclerosis) is a wasting disease of the brain, usually of in- 
sidious onset and slow course, marked by alteration of the dispo- 
sition, signs of insanity, delirium of grandeur, affection of speech,, 
tremor of the lip and tongue, loss of light reflex in the iris with other 
signs of tabes dorsalis, intercurrent apoplectic 'and epileptiform at- 
tacks, irregular — i.e., fitful — but progressive degradation, and death. 



DEMENTIA PARALYTICA. 775 

Dementia paralytica is a frequent disease, but is often overlooked 
for months or years, or diagnosticated under some of its advanced 
or grosser signs as ''paralysis/' "insanity/ 5 or "softening of the 
brain." The credit of the separation of the disease as a definite 
malady is due to the distinguished alienists of the old French school, 
especially to Calmeil and Esquirol. 

Etiology. — The most common cause of dementia is syphilis, but 
the disease occurs, not as an immediate complication, but as a remote 
sequel of syphilis. With tabes dorsalis, many of whose symptoms it 
shows, dementia paralytica is not a para- but a meta-syphilitic phe- 
nomenon. The relation of alcoholism is neither so strictly defined 
nor so generally accepted. Brain worry, especially from failure in 
life, is often assigned as a cause, without other reason than sequence. 
Real brain work — i.e., intellectual work — produces no dementia. 
On the contrary, brain work protects the brain from waste. Hered- 
ity plays the same role as in most nervous diseases — that is, epilepsy, 
hysteria, insanity, etc., in the ancestry predispose to dementia in 
posterity. Dementia is a disease chiefly of the male sex, of maturity, 
about forty, and age. 

Symptoms. — The mental faculties suffer first, as a rule, and the 
disturbance begins in the sphere of the emotions. The patient be- 
comes irritable, more especially sensitive. He is easily excited, 
angered, or hurt. He flies into a passion or weeps without apparent 
cause or from some imaginary cause. He may, exceptionally, ob- 
serve the change himself; as a rule the friends notice it first. What 
pain is endured by silent sufferers (relatives and friends) for months 
or years is only learned as the cause is understood with the lapse of 
time. 

Most patients enjoy good health at the start and often far into 
the course of the disease. Sometimes, with the appetite of a glutton 
and the indolence of ease, there is unusual euphoria. 

Most patients are optimistic, or are for a time serenely, even inor- 
dinately, happy. They soon begin to entertain ideas of grandeur. 
They imagine themselves endowed with genius, wealth, power. 
One patient, treated by the author, owned all the land in the State of 
Ohio and had gigantic schemes for the disposition of it. Another 
had invented a machine of "oiled walnut and steel wheels" — this 
was all he knew of the construction of it — which he intended to fix 
on top of the Mechanics' Institute, whence he would regulate the 
movements of the planets. 

In and bordering on this state of mind men have disposed of their 
possessions, dissipated large fortunes, and contracted heavy debts. 

In exceptional cases the opposite condition prevails. The patient 
falls into melancholy, sits dejected and distrustful, still and silent, 






776 DEMENTIA. PARALYTICA. 



the entire day. Attacks of this kind occur also in the more common 
states of expansive delirium; but they are usually transitory, lasting 
a day or two, or even a week or two, to be substituted by the condi- 
tion more natural to the disease. 

These changes are light or severe in individual cases, but are in 
either case appreciated by intimate associates, and soon, because 
permanent, come to be generally known. In other words, the char- 
acter of the individual is changed. 

At this time, or before the change has been noticed — for the 
observance of change depends also upon the observer — evidence of 
paralysis begins to appear. It shows itself first in the face and 
tongue, and is noticed especially or obtrusively in the speech. Articu- 
lation becomes difficult, syllables and words are dropped or confused. 
The f change is noticed first with unusual words, and the speech is 
much like that of alcoholism, which indeed produces a dementia of its 
own in time. Thus the patient will say "incalable" for "incalcula- 
ble," " artrerrilery " for "artillery," "eletrity" for " electricity," etc. 
The attempt to pronounce the phrase "mathematical demonstration" 
excites a smile of compassion, at least. A good test is such a demon- 
stration, whereby it is seen that the patient may still perform sums 
in simple addition, but in multiplication he is at fault, and in division 
fails entirely. So much here depends, however, upon the amount 
and direction of previous training. At this time — as a good test of 
the lapse of memory — it is difficult for the patient to recall the date 
of his birth, something that everybody knows. 

Soon — that is, sooner or later — the lower lip trembles. The pa- 
tient looks as if about to burst into tears. In more advanced cases 
the lip falls away from the teeth. The tongue is tremulous ; so 
much so, often, that the patient cannot protrude it, or, protruding 
it, cannot control it. Fibrillar twitchings and pareses affect also 
other muscles of the mouth and cheeks, so that food may fall from 
the mouth, and the patient at an early stage may have to be fed. 
Later there may be also difficulty with deglutition, so that the dis- 
ease may resemble or be associated with bulbar palsy. These bad 
signs may, however, all disappear again, and the patient survive a 
year, as in the case of a colleague of the author, or longer, as in 
recorded cases. 

Many of the symptoms of tabes are now wont to appear. Thus 
there is, or may be, paresis or paralysis of the bladder (a very ugly 
complication, necessitating great care with the catheter), absence of 
knee jerk, loss of reflex in the pupils, impotence, ataxia, paresthesia, 
or pains, though the pains are never as severe as in tabes. Mi- 
graine, supra-orbital neuralgia, scotoma, monoplegia of short dura- 
tion, may vary the scene. Charcot says certain patients present 



DEMENTIA PARALYTICA. 777 

themselves to the physician with sensations of distress in the tongue, 
( ' apprehensive of cancer of the tongue," and will not be assured to 
the contrary, as prodromata of paralytic dementia. If these or 
similar sensations, more especially formication and numbness of the 
limbs, are felt in association with disturbance of speech and altera- 
tion of disposition in a middle-aged man in previous health, the dis- 
ease is probably dementia. 

It must be remembered, however, that no one of these symptoms 
is essential to a diagnosis. The knee jerk may persist in some cases ; 
it may be increased and associated with spastic contractions. 

More characteristic events are the apoplectiform, more strictty 
epileptiform, attacks which set in later in the course of the dis- 
ease, sometimes to cut it short fatally ; oftener to be recovered from 
rapidly, but with life on a much lower plane. 

The patient may now find it difficult to express himself in any 
direction. He stops in the middle of a sentence, loses the word, 
loses the thought, is vacant, as if a veil had fallen between. 

Morbid Anatomy. — The whole brain is atrophied. The pia is 
thickened, opaque, and adherent. The vessels show signs of athero- 
matous change. The hyperplasia of the connective tissue is so great 
as to have led to the view that the process was essentially an inter- 
stitial encephalitis. In bad cases the surface of section, with its in- 
durations and vacuoles, looks like the surface of a piece of Swiss 
cheese. The disease begins, however, always in the nerve elements 
themselves. The convolutions are small. The ganglion cells are de- 
generated. Prolongations, poles, are lost. Nerve fibres are shriv- 
elled. The same degenerative, indurative changes are found in the 
cord with the evidence of more or less extensive tabes dorsalis. 
The whole process impresses the observer as the destruction and 
wreck of a general diffuse sclerosis, which, in fact, the disease is 
declared to be. 

The diagnosis is easy in a case with all the symptoms set in 
course. It rests chiefly upon the change of disposition, affection of 
speech, fibrillar tremor, especially of the tongue, the delirium of gran- 
deur, or, exceptionally, the melancholia, the epileptiform attacks, etc. 

But the diagnosis may be difficult or impossible at the start. 
Here must be taken into account the finer changes of disposition or 
temperament, attacks of migraine, double vision, the altered hand- 
writing, in association with one or more of the more distinctive signs. 

Dementia paralytica must be differentiated from the dementia 
which may follow or occur in the course of epilepsy and alcoholism, 
as well as from the dementias secondary to mania, melancholia, pa- 
ranoia, or other pure psychoses. The preceding history helps to make 
this diagnosis. Senile dementia is the imbecility of old age. 



778 AVOCATION NEUROSES. 

Prognosis and Course. — The disease is chronic, and, though 
subject to remissions and periods of quiescence of weeks', months', 
even years' duration, it is, as the name implies, progressive. Thus 
dementia may last for years with exacerbations or with such appa- 
rent improvements as to make an absolute statement of the probable 
duration of life impossible. Galloping cases may take life in a 
month. Protracted cases last ten years. Average cases extend from 
one to three years. Death is by an apoplectic attack, by cystitis, de- 
cubitus, intercurrent pneumonia, marasmus. 

Treatment. — As in the case of its allies and congeners, the other 
scleroses, the treatment is wholly symptomatic. States of irritation 
are subdued by the bromides, gr. xxx.-xl. largely diluted ; sleep- 
lessness is allayed by trional, gr. xv. in a cup of hot tea at bedtime. 
All forms of alcohol are to be avoided. 

The judicious use of morphia in small daily dosage, by stimulat- 
ing brain cells not yet attacked or entirely destroyed, will postpone 
the wreck which is in all cases inevitable at last. Close attention 
must be paid to the bladder and bowels. 

Life is best prolonged by peaceful surroundings. When the pa- 
tient is gentle or childish he may be kept at home ; where violent 
he should be sent to an asylum. 

AVOCATION NEUROSES. 

Avocation neurosis, the most common example of which is 
writer's cramp, is an expression of exhaustion of the nerve centres. 
It is the result of the excessive use of the same muscles in the same 
way. The neurosis may show itself in other forms of nerve exhaus- 
tion than cramp. The act of writing, including typewriting, fur- 
nishes the largest contingent of cases ; but as other avocations may 
produce the same result, the diseased state is better known as an avo- 
cation neurosis. Thus typical cases are encountered among piano 
players. Reuter recorded the case of a celebrated composer in whom 
the right middle finger had refused service for ten years on account 
of spasmodic extension whenever he sat down to play. Violinists 
are not exempt. Berger mentions the case of a hypochondriac vio- 
linist who was seized with pain in the left shoulder and spasmodic 
cramp of the left hand, which he could prevent only by holding the 
instrument in an unusual way. Tailors and fine-sewing women are 
sometimes attacked with a " stitch cramp." Duchenne described a 
case attended with a spasmodic rotation of the arm inward. Onimus 
reported cases among telegraphers, and Hamilton mentions the let- 
ters most difficult of record in these cases. Cigarmakers, cow 
milkers, watchmakers, shoemakers, smiths, even pugilists, have all 
been unfitted for their avocations by like conditions. 



AVOCATION NEUROSES. 779 

The disease does not confine itself to the upper extremities and 
trunk. Men who have had to tread mills have been seized in the 
sole of the foot. Scissors grinders, treadle operators, and sewing- 
machine workers may be affected in the legs. The danseuse on the 
tiptoe is not infrequently affected in the muscles supplied by the 
tibial nerve. 

Etiology. — Aside from the avocation, the disease belongs to the 
neuropathic temperament. Individuals of irritable, sensitive ner- 
vous systems, with multiform hypochondriac or other functional 
neurosis, are most frequently affected. Thus the avocation neurosis 
occurs most frequently in people affected with neuralgia, headache, 
facial spasm, strabismus, stuttering, etc. It has been noticed in con- 
nection with chorea, epilepsy, paralysis agitans, and psychoses. 
Alcoholism, onanism, sexual excesses, precipitate attacks. Patients 
themselves often show other nervous disturbances, as irritability, 
sensations of pressure about the head, vertigo, palpitation, nervous 
dyspepsia, etc. The condition is most apt to occur with the mechani- 
cal writers, especially with those who take pains to write well and 
attend more to the form than to the meaning of words. Authors 
seldom suffer. Clerks, secretaries, amanuenses, bookkeepers, are 
the victims of this disease. Cramped surroundings, bad postures, 
wrong methods of writing and holding the pen, hard pens, are pre- 
disposing factors. 

Symptoms. — The disease begins with a sense of weakness and 
weariness ; the hand and arm suffer early fatigue. The sensations 
disappear with cessation of writing, but with its resumption cramp 
soon supervenes, the fingers close about the palm with the peculiar 
pain characteristic of cramp. Effort of the will, instead of subdu- 
ing, aggravates the condition. Rest restores tone to the overworked 
muscles, and the cramp ceases. But work after too short an inter- 
val is followed sooner and sooner by cramp more and more profound, 
until finally the spasm may extend up the arm to the forearm, neck, 
and even the face. The author had a case in which the spasm of the 
arm, neck, and face became epileptiform. The individual, a clerk 
in the auditor's office, had his head drawn down on his shoulder and 
his hand twisted backward during the cramp. The pain he would 
experience at this time would cause him to cry out. Thus enforced 
work extends the disease to induce finally organic lesion in the cord. 
Palpitation of the heart, precordial anxiety, conditions bordering 
on epilepsy, develop in the history of the unfortunate individuals 
who must continue to work. 

But cramp does not constitute the sole or even a necessary factor 
in the symptomatology of the disease. Many cases show no cramp 
at all, and the disease expresses itself in other forms of muscular 



780 INSOLATION. 

exhaustion — to wit, tremor and paralysis. But cramp is the most 
frequent symptom. Thus in the sixty-four cases recorded by Berger 
twenty-four were purely spastic, ten purely paralytic, and eight 
purely tremulous. The remaining twenty-two cases were mixed • 
cramp was present in all in thirty-four cases. The kind or form of 
neurosis with which the patient is afflicted is easily discovered. In 
the use of the pen the spastic variety makes zigzag lines, after the 
manner of a man writing in a wagon jolting over a rough road ; the 
tremulous is the chirography of extreme age, the letters are small 
and wavy ; the paralytic variety soon stops — it may form but a letter 
<or two. 

The prognosis is bad. A few cases recover entirely. Indi- 
viduals unable to rest the hand or change the avocation seldom re- 
cover entirely. 

The treatment is rest. The substitution of other fingers or of 



Fig. 300.— Duchenne's apparatus for relief of writer's cramp. 

the left hand in writing changes the disease ultimately to them or to 
that side. The various mechanical devices of support may relieve at 
first, but they all prove futile at last ; tenotomy and nerve stretching 
produce no permanent results. The tone may be sustained for a 
time by strychnia in gradually increasing doses, but without rest 
there is no real relief. Aside from rest, galvanization is the true 
treatment of writer's cramp. Duchenne was forced to admit that 
faradization was of avail only in the paralytic and anaesthetic forms 
of the disease. The negative pole should be placed at the nape of 
the neck, the positive stroked over the affected muscles of the fore- 
arm. Galvanization should be gentle and the sessions brief. Hydro- 
therapy, manual gymnastics, massage, may assist treatment. 

INSOLATION — SUNSTROKE. 

Sunstroke, heatstroke, occurs most frequently in hot lands in 
summer, but may be observed also at other times and places under 
like condition, as among firemen in the holds of ships, children in 



INSOLATION. 781 

overheated apartments. Heatstroke has assumed epidemic propor- 
tions in army life. In the passage of the Mincio 2,000 of the 12,000 
soldiers at Antemarres were attacked with heatstroke, and 26 died. 
Maclean relates that at the attack on Chiang-Kiang-Foo, in the first 
Chinese war, the men, still enveloped in rigid stocks, heavy clothing, 
and impedimenta, were charging up a steep hill. A great many 
were stricken down; fifteen died almost instantly after a few convul- 
sive gasps. In army life the condition is confined to the foot sol- 
diers ; the cavalry escapes. Heatstroke occurs especially among the 
working classes. Most cases occur in hot, humid weather without 
wind or breeze. In dry weather the evaporation of sweat reduces 
the temperature. At an artificial temperature of 130° to 140° F. 
even the most profuse secretion of sweat will not suffice to protect 
the body from overheating. "When the clothes become saturated 
with sweat, exhalations of the body are prevented, evaporation 
almost ceases at the surface, the temperature continues to. increase, 
carbonic acid accumulates, and stupor, coma, and convulsions su- 
pervene. These conditions are precipitated all the more rapidly if 
the individual at the same time suffers thirst and the quantity of 
water in the blood is reduced. 

Morbid Anatomy. — Autopsy reveals early rigidity with dryness 
of the muscles. The blood is thin and dry, the brain and lungs hy- 
persemic; the left ventricle is empty, the right ventricle is full. Kos- 
ter found haemorrhages in various parts of the sympathetic. 

Etiology. — Antonini regarded sunstroke as an acute neurosis of 
the vaso-motor system. Senfleben, as the result of his observations 
on lower animals enclosed in hot boxes, ascribed the results to disor- 
ganization of the blood, disintegration of red blood corpuscles, accu- 
mulation of urea. The temperature of a rabbit put into a hot box 
at 96° F. increases to 106° F. The pulse and respiration increase 
rapidly ; the surface vessels are dilated. At 104° F. the body heat 
rises to 112° F., and the increase in respiration and pulsation is enor- 
mous. The pupils are dilated, the muscles relaxed, and death soon 
occurs from paralysis of the heart. The protoplasm of the muscle of 
mammals coagulates at 112° F., a fact alone sufficient to explain the 
cause of death. Animals perish under a continuous stay in a hot 
box, though the body heat may not rise above 108°. Under such 
conditions fatty degeneration occurs in many tissues. Wood showed 
that heating the brain of a mammal produces sudden insensibility, 
with or without convulsions, at a temperature of 108° F., and death at 
a temperature of 113° F., and that the life of the blood, as evidenced 
by the amoeboid movements of the white blood cells and the absorp- 
tive power of the red blood cells, is not destroyed by any temperature 
reached in sunstroke ; moreover, that if heat be withdrawn before 



782 CONGELATION. 






it has produced permanent injury, the convulsions and unconscious- 
ness are immediately relieved and the animal recovers. The damage 
is not dependent, therefore, upon blood poisoning, but upon the heat 
itself, and is due probably to direct effects upon heat-regulating cen- 
tres in the pons and medulla. 

Diagnosis. — Heatstroke is differentiated from apoplexy by the 
fact that the fever precedes the stroke of heat and follows the 
stroke of apoplexy. The rapid pulse and respiration of heatstroke 
are also points of distinction. 

Prophylaxis. — Heatstroke is prevented by avoidance of the heat 

* of the day, as in hot countries by a siesta at this time ; by temperate 

habits, moderation of work or marching, regulation of clothing, 

abundance of drinking-water, which should be taken frequently 

rather than in large quantities. 

The treatment is the application of cold, best in the bath, at first 
at a temperature of 80°-85°, and then rapidly reduced with ice. 
The patient, on withdrawal from the bath, should be quickly dried 
and covered. The bath may be preceded with advantage by a 
moderateMose of whiskey with gtt. xx.-xxx. tincture of digitalis 
(Guiteras). Where this treatment is not practicable the patient 
should be douched at once from the nearest water supply, and 
masses of ice may be rubbed over the head and body. Patients 
once affected with heatstroke suffer for a long time, sometimes for 
life, under subsequent exposure to heat. Attacks of epilepsy may 
ensue upon each occasion. Strychnia gr. 4V - 2V best obviates the 
cardiac and cerebral depression following sunstroke. 

CONGELATION — FREEZING. 

The human body can endure wide ranges of temperature. If the 
air be dry, life is possible at a temperature of 212° F., and at the low- 
est grades, even below —50° F., or any temperature encountered any- 
where on the surface of the earth. Consequently death by freezing- 
is not common. The various expeditions made to the North Pole re- 
cord no death by freezing. When it occurs, it is met with, of course, 
most frequently in the colder climates, Russia, Siberia, etc. , and in 
the country rather than the city, as in long night rides or when trav- 
ellers are lost in the snow. But statistics differ. Samson-Himmel- 
stern, St. Petersburg, found death by freezing 16 times in 220 au- 
topsies in seven years. Dieberg puts the proportion at ten per cent, 
while Caspar-Liman, Prussia, in 100 cases met with but 2 which 
were said to be deaths by freezing. Here, with us, death by freezing 
occurs but once in three or four years, and then usually in the case 
of a street-car driver, who is sometimes found frozen at his post. 

But while death from freezing is uncommon, local congelations 



CONGELATION. 783 

are very frequent. In St. Petersburg, 1870, there were but 3 deaths 
from freezing, but 700 cases required treatment. In a single hospi- 
tal there occurred in a decade 494 cases (456 males) with 42 deaths, 
all from complications which occurred as sequelae — thus, 18 from 
pyaemia and septicaemia. 

There is no thermal or athermal death point. Reincke once found, 
in the case of a drunken laborer frozen on the street, a temperature 
of 75° F. in the rectum. The patient nevertheless recovered. An 
animal (rabbit) cooled down to 66° F. cannot recover of itself, but it 
may recover under heat and artificial respiration, even after appa- 
rent death for forty minutes. Walther was able to recover animals 
from a body temperature as low as 48° F., and Horwath young ani- 
mals from a temperature as low as 40° F. 

The temperature at which a man will freeze depends upon vari- 
ous circumstances, as age : the old and the very young quickly suc- 
cumb ; the aged lose heat quickly on account of feeble circulation ; 
the new-born part with it readily, notwithstanding the active heart, 
on account of the slight mass of the body. Clothing, shelter, mo- 
tion, wind, dryness and moisture of the atmosphere, make a differ- 
ence. Hunger makes ready victims. Wounds, especially those at- 
tended with loss of blood, greatly reduce resistance. A powerful 
influence is exerted by depressing mental emotions. In the retreat 
from Moscow the French suffered appalling mortality. Larrey re- 
lates that on January 2d, 1845, in the retreat toward Setif, though 
the temperature was only 35° F., 208 of 2,800 soldiers perished from 
cold ; and of the remainder, 525 had to be taken to the hospital, 
where 21 subsequently died. These men were hungry, wet, and cold. 
Under such conditions men have died from freezing at temperatures 
where other men were enjoying themselves skating upon ice. 

Alcoholism is the most frequent of all the conjoined influences. 
Two-thirds of all the cases of freezing in St. Petersburg occur among 
drunkards. Liman declares that he never saw an unmixed case of 
freezing. Death results from the combined effect of hunger, sick- 
ness, alcohol, and cold. 

There is no duration of exposure to cold which is necessarily fa- 
tal. Remarkable experiences are related by the monks in the Swiss 
mountains. Krajewski * reports that a Russian peasant was found 
living under snow after twelve days' exposure. This man recovered 
after two months' illness. 

The symptoms of freezing are general and local. 1. There is 

first a sensation of chilliness and a feeling of intense cold, which 

increases to actual suffering. Drowsiness sets in and the tendency 

to sleep becomes irresistible ; the special senses are obtunded, the 

1 Schmidt's Jakr b tidier, jL 861, Bd. ex., p. 330. 



784 CONGELATION. 

sight is veiled, the hearing dulled, the touch blunted ; and though 
the patient may resist sleep for a time, with the knowledge that to 
yield to it is fatal, he finally, if unsupported, falls senseless to the 
ground. Death now occurs rapidly or slowly, according to circum- 
stances. When death is rapid it is usually preceded by bleeding 
from the nose, often by involuntary and unconscious discharges. 
When it is more slow the pulse is gradually reduced to 40-50, res- 
pirations to 8, per minute. It may be days before death finally oc- 
curs. When the patient recovers from a severe case he is apt to suf- 
fer violent headache or delirium ; sometimes paralysis ensues. 

2. The first effect of cold is contraction of the vessels, so that the 
surface becomes pale or white. The vessels subsequently dilate 
and the surface is reddened or rendered blue or livid. These lo- 
cal effects are seen on the exposed extremities, the ears, the nose, 
fingers, and toes, where they constitute what are known as chil- 
blains or frost erythemata— commonly, frost bites. 

Freezing occurs in three modes of severity : 1. The vessels are 
simply dilated and are again restored and the parts recover their 
natural tone ; or the vessels remain dilated or more especially dilat- 
able, so that surfaces once frozen show hyperemia upon every new 
exposure to cold. Such surfaces are attended with sensations of 
burning or numbness, or, more particularly, intolerable itching, 
especially at night, which is only partially relieved by scratching or 
other irritation. Sometimes this susceptible condition, which rep- 
resents a subparetic condition of the capillaries, remains for many 
years. 

2. In the stage of vesiculation blisters are formed. Entire resti- 
tution is also possible from this stage. 

3. Gangrene with destruction of tissue. 

* Winiwarter describes a peculiar thickening of the intima which 
occurs in arterioles subject to freezing as a cause of occlusion and 
gangrene. Malum perforans pedis has been observed to occur after 
congelation. Though the patient may recover with life, with the 
loss of gangrenous parts, he may subsequently succumb to sepsis, 
tetanus, etc. 

Morbid Anatomy. — Congelation has a medico-legal aspect. It 
is sometimes important to know if the freezing was a homicide. The 
idea of suicide cannot be entertained, as the suffering is too great 
and the victim would necessarily seek shelter. There is no doubt 
that new-born babes have been killed by exposure to cold. There 
are, however, no signs by which the fact could be determined that a 
body had been frozen to death. The body is of course rigid. It is 
sometimes frozen through, so that the contents of the stomach are 
found solidified and blood is actually frozen in the heart. The natu- 



CONGELATION. 785 

ral post-mortem rigidity persists after the body has been thawed out. 
Sometimes extremities, fingers, toes, nose, ears, etc., have been bro- 
ken off ; this is a very rare occurrence and is no proof of congela- 
tion. The cranial bones have been found separated — proof, however, 
only of the fact that water expands and bursts the vessel that con- 
tains it, exactly as it bursts an earthen jar. 

The internal organs are found, as a rule, intensely congested. 
This is the case also in alcoholism, the condition especially to be dis- 
tinguished, but often impossible of distinction because conjoined with 
congelation. One thing is certain, a frozen body does not decompose, 
and the evidence of decomposition proves that the body was exposed 
after death. This point is often of value in cases of long absence, 
as when an individual has disappeared in the summer and the body 
has been found in the winter, frozen, and in a state of partial decom- 
position. 

Rather more valuable evidence is furnished by the redness of the 
skin and redness of the blood ; but both states are not always present 
in freezing, and are sometimes present in death from other causes. 
Redness of the skin, or red patches on the skin, are more common 
than redness of the blood. These conditions are due to the direct 
effect of cold on the haemoglobin, and are always post-mortem phe- 
nomena. 

The cause of death from freezing has been variously attributed to 
direct action on the corpuscles (Rollet), to influence on the nervous 
system (Crecchio), to congelation of the muscular tissue (Horwath), 
but, as Blumenstock remarks, the action is too complex to attribute it 
to any one cause. 

The prognosis depends upon the grade of freezing, the strength 
of the individual, and various surrounding circumstances. Most 
patients recover from frost bites in the course of time, and recovery 
is always possible from septic states, and even after gangrene with 
sloughing, though the prognosis here is necessarily grave. 

The treatment in local frost bites consists in the slowest possible 
application of heat, as by means of friction with snow and later with 
mild anodyne applications, as with equal parts of linseed oil and lime 
water (Carron oil), or diachylon ointment. The indications are to 
restore heat gradually and to relieve stasis. Stasis is best relieved 
by vertical suspension. The hands or feet are put at right angles 
to the body, or at least reposed upon inclined planes. All local hy- 
peremias disappear at once under this treatment. Chilblains are 
best treated by strapping with adhesive plaster. The strapping 
must be close and firm, and the straps should be allowed to stick or 
stay on for three days. If the surface is broken the salicylated plas- 
ters are the best. 
50 



786 SATURNISM. 

Frost bites of the second grade are treated exactly as are burns, 
by mild emollient applications, as the Carron oil referred to. The 
following is a fine dressing for burns : 

B Europhen. 3.0 

Olei olivfB 7.0 

Vaselini 60.0 

Lanolini 30.0 

M. S. Apply to the surface. 

Care should be taken not to remove the cover of a blister, which 
^ is itself the best natural protective. Gangrenous processes fall in the 
domain of surgery. 

SATURNISM — LEAD POISONING. 

Saturnism, plumbism (plumbum, lead), occurs in two forms, 
acute and chronic, entirely different from each other. Acute Lead 
Poisoning is not common, as very large quantities of any salt of 
lead are necessary to produce dangerous effects. As much as a 
drachm of the sugar of lead is sometimes taken without evil effects. 
Yet cases have occurred where lead poisoning has assumed epidemic 
proportions. Bancks, of Stourbridge, reported such a case, where 
thirty pounds of acetate of lead became mixed by accident with 
eighty sacks of flour, and the whole mass was made by the bakers 
into bread, from the eating of which five hundred people were 
attacked with lead poisoning. Poisoning sometimes occurs from the 
glaze of crockery ware, solder of metallic kitchen vessels, white lead 
used in confectionery, red lead in the preparation of lobsters. 
Babies may be poisoned with the lead of rubber nipples, from 
painted toys, glazed cards, etc. 

Acute lead poisoning runs its course with the symptoms of gas- 
tritis, pain, vomiting, and, in bad cases, rapid collapse. The 
diagnosis is established by the detection of lead in the vomited 
matters. The ammonium sulphide produces a black precipitate in 
acid solutions which contain less than the one-hundred-thousandth 
part of a lead salt. 

Chronic Lead Poisoning is much more common, as any salt of 
lead, even the most insoluble, will produce symptoms in the course of 
time. The condition was known in the remotest antiquity. Avi- 
cenna described it. The first exhaustive monograph was written by 
Tanquerel des Planches (1830) . 

Chronic lead poisoning is observed most frequently in workers in 
lead, in painters, plumbers, glaziers, enamellers, etc. Snuff and 
chewing tobacco take up two and one-half to three per cent of lead 
from lead foil envelopes. Poisoning occasionally results from the 
use of water from lead pipes, though protection is here usually secured 



SATURNISM. 787 

by the fact that the pipe becomes coated with the insoluble sul- 
phate. Very small quantities of lead suffice to produce symptoms. 
The house of the king of France was poisoned in the course of seven 
months by drinking-water which contained 0.0002 per cent. But 
very small quantities are ever found in the body. Thus Heubel 
could detect in his experiments upon dogs, after long administra- 
tion of the acetate of lead, in the bones but 0.025 per cent; in 
the kidneys, 0.012 per cent ; liver, 0.01 per cent; spinal cord, 0.006 
per cent ; brain, 0.004 per cent ; muscles, 0.002 per cent ; intestines, 
after separation of contents, but a mere trace. 

Symptoms. — Lead poisoning shows itself in four sets of symp- 
toms : colic, affection of the joints (arthropathy), paralysis, and dis- 
ease of the brain (encephalopathy). Colic is b} T far the most fre- 
quent symptom. It may come on gradually or suddenly. It occurs 
in attacks of intense griping pain in the region of the umbilicus 
or anywhere about the abdomen. The pain is often attended by 
nausea, retching and vomiting, sometimes by excessive tenesmus. 
The pulse is retarded sometimes to thirty in the minute — a charac- 
teristic feature. The tongue is coated, the breath offensive. A blue 
line, from deposit of lead, is often seen oil the gums. The abdo- 
men is retracted, the bowels constipated. The attack lasts, with 
exacerbations and remissions, several days to a week, and termi- 
nates gradually, sometimes suddenly. The prognosis, aside from 
other symptoms of lead poisoning, is favorable. 

Arthralgia manifests itself injxmis in the joints, chiefly of the 
lower extremities, especially the knee; and cramps of the muscles, 
especially the flexors of the leg, which sometimes also show tremor. 
This condition of tremor may be seen also in other muscles, even fa- 
cial muscles, which are never affected with any other expression of 
the disease. 

The paralysis, on the other hand, affects principally the exten- 
sors, and of the upper rather than the lower extremities. Paralysis 
of the extensors of the hand, wrist-drop, with preservation of the 
power of pronation and supination, is characteristic of lead poison- 
ing. The triceps and deltoid are next most frequently affected. Sen- 
sation is not disturbed, but trophic change is always present and is 
manifest by wasting, which is equalled only by that which occurs 
in progressive muscular atrophy. The paralysis may disappear rap- 
idly, or remain for years or for life. 

The brain symptoms — encephalopathies — are distinguished by 
their gravity. They occur usually late, but may supervene early in 
the course of lead poisoning. The most common form is eclampsia, 
which is distinguished by the fact that it is never preceded by an 
aura and is rarely attended with complete loss of consciousness. 



788 ALCOHOLISM. 

The patient may pass from one attack to another in the course of 
several days, and any attack may prove fatal. Amaurosis, wholly 
of brain origin, with perfectly normal conditions about the eye, is not 
uncommon. Attacks of mania, melancholia, and various psychoses 
vary the scene. 

The treatment of acute poisoning consists in washing out the 
stomach with the stomach tube or stomach pump, in the administra- 
tion of the alkaline sulphates of sodium, potassium, and magnesium. 
The patient should be purged with Epsom salts. In the absence of 
antidotes, milk and albumen (white of egg) should be administered 
freely. 

Prophylaxis of chronic poisoning is best observed by cleanliness. 
Painters should not put paint brushes in their mouths, and all 
workers in lead should practise ablution before eating. Work- 
ing rooms should be better ventilated, etc. 

The treatment of chronic lead poisoning consists also in the fre- 
quent use of the stomach tube. Dilute sulphuric acid should be 
taken with the drink. Iodide of potassium is administered inter- 
nally with the view of making soluble compounds which may be 
eliminated by the kidneys. Sulphur baths are recommended. Sem- 
mola reports some remarkable results with the electrolytic action of 
the constant current. The positive pole is put on the tongue, the 
negative at the pit of the stomach ; later the poles are changed to 
the spine and abdomen, sessions daily, ten to fifteen minutes' dura- 
tion, strong currents, one hundred to one hundred and thirty milli- 
amperes. Obstinate, even grave, symptoms disappear entirely in 
time. Removal of the cause, change of work, is, unfortunately, 
often a necessity. 

ALCOHOLISM. 

Alcohol (Arabic, kahala) may be disposed of as food in quanti- 
ties of one pint of beer, or one-half pint of Rhine wine, or four ounces 
of sherry wine, or two ounces of whiskey per day. Beer contains four 
per cent, Rhine wine eight per cent, sherry twenty per cent, whiskey 
forty per cent of alcohol. Quantities above this amount constitute 
excess which does damage to tissue and leaves lesions. 

Alcohol whips up the heart, feeds the brain, and thus forces 
energy in states of exhaustion, but at the final expense of the ma- 
chine, which should recuperate through rest, "The worker in the 
use of alcohol consumes his capital instead of his interest, with the 
inevitable result of bankruptcy in time" (Sippe). 

Drinkers have less working capacity, less endurance, and shorter 
life than the temperate or totally abstinent. Thus the mortality 
statistics of a leading insurance company of London — which made 



ALCOHOLISM. 789 

two classes, one of the totally abstinent and the other of all others — 
showed for the abstinent seventy-one per cent and for the rest ninety- 
seven per cent, a difference of twenty- six per cent in favor of the 
abstinent. 

Billings makes this fact very plain by the following table, show- 
ing the mortality of dealers in liquor (twenty-five to sixty years of 
age) from various diseases, compared with that of men generally of 
the same ages : 

Liquor dealers- Men generally. 



55 


10 


240 


39 


13 


3 


200 


119 


26 


3 


83 


41 


140 


120 


761 


653 



Alcoholism 

Liver disease ... 

Goat 

Diseases of the nervous system 

Suicide 

Diseases of the urinary system 

Diseases of the circulatory system 

Other diseases 

All causes 1521 



Alcoholism as a disease occurs in two forms, acute and chronic. 

Acute Alcoholism shows itself with loss of consciousness, as a 
sudden intoxication. The face is flushed and dusky, the eyes promi- 
nent and staring, the pupils dilated, the surface is cool and insensible, 
the pulse retarded and irregular, the respiration stertorous. The 
breath smells of alcohol, as does also the vomited matter which is of- 
ten found upon the clothes or in the vicinity of the patient. The tem- 
perature may fall as low as 75 c F. The individual thus affected is 
said to be " dead-drunk." The patient may succumb to heart failure 
and collapse in this attack of coma, or may recover after a stage of 
long and heavy sleep. Coma which lasts over twelve hours is usually 
fatal. The victim of intoxication by alcohol is especially liable to 
suffer and succumb to epilepsy, pneumonia, oedema of the lungs, and 
failure of the heart. Under exposure in cold weather such patients 
easily freeze to death. 

Cheoxic Alcoholism reveals itself in organic disease and in vari- 
ous neuroses, including a special form known as delirium tremens. 
Catarrh of the stomach, cirrhosis of the liver, chronic nephritis, fatty 
degeneration of the heart, atheroma of vessels, are the common 
manifestations of continued abuse of alcohol. The neiwous system 
is affected in all its functions, in every direction. Disturbance of 
motion shows itself in tremor, which especially affects the extremi- 
ties and tongue, and occurs as fine rhythmic oscillations. Muscular 
force is everywhere reduced. The tone of the face is lost, the 



790 DELIRIUM TREMENS. 

patient staggers in his gait, the grasp of the hand is enfeebled. 
More pronounced are the disturbances of sensation, which occur 
as paraesthesiae, hypersesthesise, and neuralgias, an especial form of 
which is set apart as the alcoholic neuritis. Disturbances of special 
sense are manifold. Flashes of light, derangements of vision, ring- 
ing in the ears, etc., are common signs. Alcoholism shows nearly 
every form of psychosis. The memory is impaired, comprehension 
enfeebled, the power of concentration lost. Victims of alcohol are 
full of bravado, often of brutality, but fail in real courage. Alcohol 
begets suspicion. A common delusion is a suspicion of marital infi- 
delity, an act of which the patient may claim to see before his eyes. 
Outbreaks of mania are not infrequent, and are often distinguished 
with difficulty from the initial stage of paralytic dementia; or mania 
alternates with melancholia. The psychoses take sometimes the 
form of paranoia with sleeplessness and delusions. The patient is 
persecuted with visions. Distinctive features of the delusive vision 
are the number, movement, and minuteness of surrounding objects. 

Treatment. — In acute intoxication the excess of alcohol may be 
allowed to eliminate itself in sleep. In recent ingestion the stomach 
may be washed out with the tube and mouth gag or the stomach 
pump. Stimulation of the respiratory centre by cold affusion is the 
most effective restorative. The extremities should be kept warm. 
The alcohol habit may be arrested and aversion for liquor excited 
for a time by the subcutaneous injection of strychnia nitrate gr. ■£$, 
and atropia sulphate gr. T ^, twice daily for two or three weeks. Iso- 
lation in an institution for the purpose is often a necessity. Perma- 
nent cure may be effected only by strengthening the will, wherein 
"the patient must minister unto himself." 

DELIRIUM TREMENS — MANIA A POTU. 

A special form of alcoholic intoxication distinguishes itself by the 
prominence of two symptoms, delirium and tremor, and has hence 
received the appropriate name, delirium tremens. The disease is 
usually prefaced for several days by excessive nervousness and sleep- 
lessness, and insomnia is a third cardinal symptom of this disease. 
The victims of alcoholism are haggard and worn from loss of sleep. 
Delirium tremens occurs only in certain individuals, not in all cases 
of alcoholism. Victims of this affection come of neuropathic stock, 
or suffer themselves some other form of neurosis. According to 
Westphal thirty per cent of cases are victims of epilepsy before the 
first manifestation of delirium tremens, and thirty per cent of the 
remainder are seized with epilepsy during attacks. This fact has 
more to do with the development of delirium tremens than the quan- 
tity of alcohol alone. Delirium tremens is an expression also of ex- 



DELIRIUM TREMENS. 791 

haustion of nerve centres. So long as food is retained and digested 
delirium tremens does not occur. The condition develops only in the 
presence or as the result of a subacute or chronic gastric catarrh, 
which may be itself in turn the effect or expression of the abuse of 
alcohol. A trauma, a surgical operation, a severe intercurrent dis- 
ease, pneumonia, may precipitate an attack. 

The delirium is peculiar, and is distinguished especially by ex- 
pressions of fear. Most patients do not " see snakes/' as is com- 
monly believed. Patients surrounded by animals are plagued by 
their number rather than their size. Bugs, flies, fleas, beetles, in 
millions and myriads, crawl about their beds, crowd the air of their 
rooms, fill the whole space. More frequently patients make of objects 
in their vicinity fantastic creatures, or look upon attendants as 
thieves and assassins, from whom they start and shrink with fear. 
Chronic psychoses may develop from these states. Mendel says 
that Lasegue reported the case of a patient who maintained that his 
family had cut off his penis and substituted for it an organ of lead, 
which was not properly fastened and greatly incommoded him in 
getting about. Such patients often report with circumstantial evi- 
dence crimes which they have committed or seen committed, but 
which have no foundation in fact. Suicide or attempted suicide oc- 
curs in six per cent of cases of delirium tremens. 

The tremor shows itself especially in the hands, arms, tongue, 
and lips. The double or disturbed vision, which leads to so many 
ludicrous mistakes in the drunkard, is a tremor or paresis of the mus- 
cles of the eye. The perception of sensation is even more com- 
pletely annulled. The subject of delirium tremens loses all sense of 
pain. He lies out over-night until his extremities are frozen, and 
the victim who has fallen in his flight from imaginary danger will 
lift himself up on broken legs or hobble about on a cracked pelvis, 
oblivious of pain. 

The degree of insomnia is evidenced by the quantity of opium 
or other anodyne necessary to secure sleep. Thomas Sutton, who 
named the disease, gave one of his patients forty-two grammes of 
opium in all without securing the desired effect. The stage of deli- 
rium lasts two to ten days, and terminates with a long, heavy sleep. 

The diagnosis rests upon the peculiar delirium, tremor, andinsom- 
nia. The disease is distinguished from the delirium of typhoid fever, 
septicaemia, etc., by the absence of fever in pure delirium tremens. 

The prognosis is grave, though most patients recover from the 
individual attack. The immediate outlook is determined more by 
the condition of the stomach than by any individual factor. Patients 
able to ingest and digest food speedily recover. The condition of 
the heart establishes the final prognosis. 



792 COCAINISM. 

The treatment consists in restoring tone to the nervous system 
with food. Attempt to force sleep with powerful anodynes is not 
good practice. The best results are accomplished with the use, as 
soon as possible, of the stomach tube and the administration of dilute 
hydrochloric acid. Frenzied patients should be subjected only to 
that degree of restraint necessary to prevent injury. The bromides 
are prescribed as sedatives in routine treatment, but always with the 
risk of damage to the stomach. Chloral is the most powerful hyp- 
notic, and may be given with safety at night in doses of ten or fifteen 
grains to young, strong, and healthy subjects, but should not be ad- 
ministered in the presence of a feeble, fatty heart. In these cases 
the best remedy is digitalis, which may be given in the form of infu- 
sion, teaspoonf ul to a dessertspoonful every two to four hours, or the 
tincture gtt. x. at the same interval. Digitalis also does damage to 
the stomach. Opium is the last resort. It is better, when possible, 
to bear with the malady for a time than to destroy or injure the pro- 
cess of digestion. The real cure of delirium tremens rests with the 
patient rather than the physician. The broken will must be built up 
by the individual himself. 

The craving for alcohol, dipsomania, is a desire which asserts 
itself periodically and leads to excessive indulgence for a period of a 
week or two, or until a gastric catarrh thus induced or a delirium 
tremens puts a stop to further drinking. Dipsomania is itself a neu- 
rosis dependent upon unstable nerve cells. The nervous symptoms, in- 
somnia, dread, tremor, which ensue in the course of such indulgence, 
though they are most severe at the close of a debauch, are caused by 
the alcohol itself and not by abstinence. Hence they are best con- 
trolled by immediate and absolute abandonment of the use of alco- 
hol — a sacrifice which can only be successfully made in an institution 
under supervision and restraint. The collapse which may follow 
such heroic treatment is obviated to some extent by the use of atro- 
pia gr. i.- § i., gtt. iij.-v. every three or four hours, or hyoscyamine 
in the same dose. The heart and the nervous system are best sus- 
tained subsequently by strychnia gr. ¥ V ter die or by the tincture of 
nux vomica gtt. x.-xx. ter die. The aromatic tincture of rhubarb,. 
3 i. ter die, diluted, is a good stomachic tonic in these cases. 

COCAINISM— POISONING BY COCAINE. 

Cocaine poisoning may be acute or chronic. Acute poisoning 
occurs in consequence of excessive use, in operations about the eye 
and throat, and after subcutaneous injections to secure anaesthesia 
for more extensive procedure (circumcision, etc. ) ; sometimes after 
injection of stronger solutions into the bladder, nasal cavity, etc. 
Keclus collected fifteen deaths, mostly from overdosage, ten to fifteen 



POISONING BY OPIUM. 793 

grains. One to one and a half grains (one-half to one grain by in- 
jection) is maximum dosage. For anaesthesia, cocaine, perfectly 
pure, should be injected into and not under the skin or mucous 
membrane. The object is to reach the nerve endings in the skin. 
The injection should be made slowly, drop by drop. Acute cocainism 
is marked by collapse, with pallor of the face, vertigo, nausea, 
precordial anxiety, cyanosis, and syncope. Poisoning in less de- 
gree is attended with delirium marked by hilarity, volubility, 
sometimes by hallucinations and mania. Convulsions may occur 
in the course of the intoxication. Anomalous cases are marked by 
cardialgia, palpitation, insomnia, amblyopia. 

Chronic Cocainism produces cachexia with nervous debility, 
neurasthenia marked by anorexia, marasmus, insomnia. Patients 
complain of dryness of the throat, palpitation of the heart, and 
suffer attacks of dyspnoea and difficulty of articulation. Chronic 
cocainism develops a peculiar paranoia, marked by hallucinations of 
sight and hearing, ideas of persecution, and attacks of melancholia. 

Tests. — Cocaine may be recovered from the urine. The addition 
of potassium permanganate produces a violet-red precipitate, which 
soon becomes brown. A solution of cocaine brought into contact 
with white filtering paper saturated in a solution of the ferrocyanide 
of potash and chloride of iron develops a. blue spot in two minutes. 

Treatment. — Acute poisoning is treated by cold douches, with 
artificial respiration and massage. Convulsions are controlled by 
chloroform or amyl nitrite. Injections of ether or caffeine sustain the 
heart until the patient can swallow, when he may be fed with black 
coffee. Morphia, gr. J subcutaneously, is also antagonistic to cocaine. 

Victims of chronic cocainism must be treated as in opiophagism. 
Real results are to be obtained as a rule only in an asylum, where the 
weak will of the patient is substituted by the strong will of authority. 

POISONING BY OPIUM. 

Poisoning by opium (onos, juice) is acute and chronic. The sus- 
ceptibility to opium differs, and the dose which may be injurious or 
fatal varies according to age and still more according to habit. 
Children are particularly sensitive. A single drop of laudanum has 
produced dangerous narcosis, and two drops have proven fatal 
through coma and convulsions. Three-fourths of all the deaths 
from opium occur in childhood under the age of five years. On the 
other hand, opium eaters may secure such tolerance as to be able to 
dispose of a drachm of morphia in a day. In these cases the mass of 
the morphia is unabsorbed. Most cases of opium poisoning in adult 
life occur among opiophagists who recommence the use of the drug, 
after cessation or reduction, with too large a dose. 



794 POISONING BY OPIUM. 

Acute poisoning shows itself in sensations of warmth, stimula- 
tion of the intellectual faculties ; later, sense of oppression, drowsi- 
ness, uncontrollable desire to sleep, and heavy slumber. Sometimes 
there is, instead of sleep, intoxication with headache, vertigo, tremor 
of the hands, twitchings, and convulsions. Itching of the nose and 
of the face, and of the whole body {pruritus opii), is a common and 
characteristic effect of opium. Erythema may develop. The patient 
recovers with a sense of languor, headache, anorexia, nausea, and 
constipation. In opium narcosis the pupils are contracted, often to 
the size of a pin's head, and are irresponsive ; the eyes are fixed, 
the pulse is irregular, the patient is unable to swallow, respiration is 
paralyzed, and death occurs with stertor and coma. 

Chronic poisoning is frequent. The subjects of chronic poisoning 
are the victims of the opium habit, which is, in places, as in the 
Easf, a national vice. Chronic poisoning shows itself as a cachexia 
with degradation of the intellectual and moraF faculties, with impo- 
tence in men and sterility in women. The continued use of opium 
begets a condition of unrest, ill-defined anxiety, insomnia, with 
gradual alienation, stupefaction, of the individual ; tremor develops, 
with pallor, parsesthesia, sometimes with albuminuria. Anorexia is 
pronounced. Chills occur, with sweats. Constipation remains ob- 
stinate, or is substituted in certain cases by diarrhoea and vomiting. 
Conditions of collapse sometimes supervene. Many of these symp- 
toms are intensified on withdrawal of the drug, and then constitute 
what are known as "abstinence signs. " There is in this state unap- 
peasable craving for morphia, which may eventuate in maniacal 
attacks. In the experience of the author a patient at the hospital 
wore out two attendants, who finally fell asleep. The patient, a 
young lady, arose from bed, made a rope of the bedclothes, let her- 
self down from a second-story window to the ground one cold Decem- 
ber night, and was found by a policeman standing at the door and 
trying to effect an entrance into a drug store. No less than nineteen 
hypodermatic syringes were removed from pockets, lining, seams of 
the suit of clothes worn by another patient, a man, a confirmed vic- 
tim of morphinism. 

Treatment. — The question is, shall the drug be withdrawn sud- 
denly or gradually? And the answer may be determined by the 
effects which supervene upon sudden withdrawal. Where the pa- 
tient is able to endure the suffering and survive the prostration, ab- 
solute withdrawal is best. The amount of suffering is less in the 
long run. Otherwise the drug may be withdrawn gradually. The 
patient must be isolated and guarded. No victim of morphinism 
may be treated successfully at home or at any ordinary hospital. 
The patient must be put where he absolutely cannot obtain opium. 



POISONING BY NICOTINE. 795 

The attempt to substitute morphia by other anodynes or hypnotics 
gives no real or permanent relief. Temporary relief may be secured 
by cannabis indica, hyoscyamus, atropia, cocaine, the bromides, etc. 
Strychnia nitrate, especially when injected subcutaneously, gr. ^V" 
-^±, in combination with sulphate of atropia gr. T t„, best supports the 
nervous system. Caffeine, strong coffee, support the heart. Irriga- 
tion of the stomach, warm baths and trional, with time, good feed- 
ing, and, as far as it may be secured, good cheer, cany the patient 
through. 

POISONING BY NICOTINE. 

Nicotine, an active principle of tobacco, is one of the most dan- 
gerous of all the alkaloids, ranking next in virulence to hydrocyanic 
acid. The quantity of nicotine varies in different kinds of tobacco. 
Common tobacco contains seven to eight per cent, finer Havana less 
than two per cent. Animals vary also in resistance to nicotine, in 
descending scale, according to Berutti and Vella: centipedes, flies, 
butterflies, spiders, fish, frogs, dogs, rabbits, and cats. A dog is 
killed by one and a half to two drops, a rabbit by one-fourth of a drop, 
small birds b} T a touch on the beak with a rod dipped in nicotine. 
Dangerous symptoms of intoxication have been observed in man at 
the dose of 0.003 gramme. Tobacco contains also other substances — 
volatile oils, pyridin, prussic acid, carbonic oxide, marsh gas, etc. 
— in varying quantities, usually too minute to produce much effect. 
Stronger tobacco can be smoked from a cigar than from a pipe, as the 
volatile and benumbing pyridin is totally consumed in the cigar, 
and only imperfectly consumed in the bowl of a pipe. 

Symptoms. — Mammals poisoned with nicotine show unrest and ex- 
citement, tremor, discharges from the bowels and bladder, stupor, 
clonic and tonic convulsions. These symptoms have been observed 
after smoking, after the use of the infusion of tobacco in therapy, in 
poultices and clysters. 

Small doses of nicotine excite the vagus and thus reduce the fre- 
quency of the heart. The blood pressure falls, with paralysis of the 
peripheric vessels. The temperature is reduced. In small quanti- 
ties, nicotine, by its effect on the nerve centres, allays nervousness, 
quiets discontent, subdues ambition, reconciles to idleness. The per- 
centage of college students who use tobacco is, as a rule, less than 
that of those who abstain. In sensitive subjects, or in excess, to- 
bacco produces anorexia, nausea, catarrh of the stomach, catarrh of 
the throat, palpitation, neuralgia of the heart, angina (pseudo) pec- 
toris, delirium cordis, tremor, nervous excitement, hypochondriasis, 
amblyopia — conditions which all disappear, to leave no lesion, on ces- 
sation of use. 



796 POISONING BY GASES. 



POISONING BY GASES. 



Gases, as they affect the animal body, are divided into the indif- 
ferent, irrespirable, and poisonous. 

The indifferent are the gases which have in themselves no injurious 
effect, but may become injurious by accumulation, simply because 
they diminish or dispel the natural air. To this category belong ni- 
trogen, hydrogen, and carburetted hydrogen (marsh gas). Nitrogen 
may occur in mines to diminish the proportion of oxygen (which 
should be twenty-one) to fifteen per cent. Such a diminution may 
* lead to emphysema ; still greater reductions may produce asphyxia. 

The irrespirable are the gases which, in slight quantities, produce 
certain injurious but not dangerous effects. Among these may be 
cited sulphurous acid, nitric acid, muriatic acid vapors, and the va- 
pors of ammonia, chlorine, bromine, and iodine. These gases are 
present or accumulate in certain trades. Sulphurous-acid gases are 
developed in the bleaching of straw, manufacture of hats and bon- 
nets, the bleaching of silk, woollen, and cotton goods, the manufacture 
of brushes, and in coal, sulphur, and silver works, as well as in the 
manufacture of sulphur acids themselves. They occur also in the 
distillation of coal. The accumulation may be but slight, one, two, 
or three per cent, according to the degree of ventilation; or it may 
increase, as in the manufacture of sulphur acids, to seven per cent. 
Sulphurous-acid gases are absorbed into the blood and act directly 
upon the nerve centres. The vaso-motor centre is at first excited, 
later paralyzed ; the respiratory centre is affected in the same way. 
The inhalation of the sulphur acids in slight quantities produces irri- 
tation of the throat, cough, angina, and bronchitis. The strong 
concentrations induce spasm of the glottis and, with a reduction of 
oxygen, asphyxia. 

The nitrates occur in the fabrication of nitric acid, nitro-ben- 
zine, and in certain copper, soda, and gold works. The vapors 
are usually present in but very small quantity; local effects are, 
however, distinct. There is irritation and burning in the nose, 
constriction with a sense of suffocation in the throat, cough, dysp- 
noea, and general symptoms of distress on the part of the digestive 
system and respiratory organs. Muriatic-acid vapors occur in the 
fabrication of soda, the vulcanization of caoutchouc, in the glazing 
of pottery, manufacture of glass, production of artificial manure, 
always only in minute quantities. Hydrofluoric-acid vapors, which 
are developed in the engraving of glass, crystal, etc. , produce irrita- 
tion of the eyelids and eyes, intense coryza, and spastic bronchitis. 
Ammonia vapors are inhaled in the manufacture of ammonia, in the 
preparation of mercury, in tanning, sewer cleaning, tobacco, sugar, 



POISONING BY GASES. 797 

and artificial-ice factories. In certain concentration ammonia pro- 
duces constriction of the chest, which may increase to suffocation, 
increase of the blood pressure, with ischuria. In such saturation the 
odor of ammonia, excreted by the sweat, emanates from the body. 
Chlorine is developed in the manufacture of chlorine, nitric acid, 
chloride of lime and the alkalies, artificial soda, and in the various 
bleaching trades. The first effect of inhalation of chlorine is irrita- 
tion of the mucous membrane of the respiratory organs. The second, 
reflex actions, especially spasm of the glottis. Epiphora, sneezing, 
cough, pains in the chest, dyspnoea, occur at once in acute cases. 
Chronic cases are characterized by blood spitting, spasm of the glot- 
tis, and pneumonia of rapid course. Workers with chlorine undergo 
emaciation, show a bad color, and suffer from catarrh of the stomach 
and chronic bronchitis. Bromine and iodine exercise similar effects. 

The poisonous gases are especially carbonic oxide (monoxide), 
carbonic acid (dioxide), and sulphuretted hydrogen. Ordinary 
illuminating gas contains a large number of poisonous gases, along 
with carbonic acid and oxide, among which may be cited ammonia, 
cyanogen, bisulphide of carbon, and sulphuretted hydrogen. Car- 
bonic oxide is a colorless, odorless, and tasteless gas, which burns 
with a blue flame. It is exquisitely poisonous to the animal organ- 
ism. Absorbed into the blood it displaces oxygen from the haemo- 
globin, and forms new combinations with the coloring matter of the 
blood, whereby the corpuscles are rendered incapable of further 
absorbing oxygen. This combination imparts the peculiar cherry-red 
color to arterial as well as venous blood. The gas does not separate 
from its combination in vacuo, but may be displaced by other gases 
or by the air pump. 

Carbonic oxide is developed also in iron smelting and in the 
manufacture of coke, in which -process coal is subjected in ovens to 
dry distillation. Carbonic-oxide gas occurs also in the usual heating 
of houses, and may thus induce poisoning. The imperfect combus- 
tion of coal develops carbonic oxide. This imperfect combustion 
occurs especially in arrangements for heating which do not admit of 
sufficient ventilation. Biefel and .Poleck give the following as the 
average composition of numerous analyses of coal smoke: carbonic 
acid, 6.75 per cent; carbonic oxide, 1.34 per cent; oxygen, 13.19 per 
cent; nitrogen, 79.72 per cent. 

Carbonic oxide does not usually accumulate in the air of a room, 
because it escapes with the products of combustion: but it accumu- 
lates in the room when the escape of gases through the chimney is 
hindered by the closure of the draught valves in the stove or furnace, 
or when the chimney is stopped by soot. Any hindrance to the 
entrance of air leads to the accumulation of carbonic oxide. The 



798 POISONING BY GASES. 

quantity of carbonic oxide necessary to make the air injurious is 
variously given by different authors. Fodor maintains that a pro- 
portion of 0. 5 per thousand continuously inhaled is decidedly delete- 
rious. Biefel and Poleck found a percentage of 0.19 fatal to rabbits. 

In poisoning by carbonic oxide there is dulness and drowsiness ; 
the face is at first flushed, later pallid, and still later livid and 
cyanotic. The stupor of the nervous system may be so great as to 
reduce to the minimum the difficulty of breathing. Sometimes there 
is dyspnoea with the convulsions of asphyxia. Suffocation may set 
in under stupor without much dyspnoea, and convulsions may occur 
only at the close. The pulse is at first full and rapid ; later, in the 
state of coma, scarcely perceptible. The temperature sinks two or 
three degrees. The urine may contain sugar and albumin. There 
is at- times local, and at times general, anaesthesia of the surface. 
Paralysis of the bladder and intestine may occur. 

Carbonic-acid poisoning occurs not infrequently in certain trades. 
The exhalation of carbonic acid from the body is in proportion to the 
quantity of gas in the air. When this proportion reaches a certain 
amount, the gas is not given off, but accumulates in the organism, 
produces dyspnoea, and finally paralysis of the sense of respiration. 
Carbonic-acid gas is thus a narcotic, and belongs to those poisonous 
gases to which the body becomes gradually accustomed. Carbonic- 
acid -gas poisoning in open air occurs in places where the gas issues 
from the earth in large amount, as in the Grotto of Puzzuoli, where it 
is, from its weight, fatal to dogs; at Pyrmont, in the poisonous valleys 
of Java, and certain places in the neighborhood of volcanoes; also in 
mines, as well as wine and beer cellars, and apartments crowded 
with people, etc. 

The treatment of poisoning by gases is the admission of fresh 
air, the use of artificial respiration, the administration of oxygen, 
and, in the case of the poisonous gases, the practice of transfusion. 

The operation of transfusion of blood itself is now done directly 
from vein to vein with the apparatus of Aveling, a procedure which 
requires some skill ; or by the use of three different syringes, that one 
maybe kept always cleaned, i.e., sterilized and warmed, ready for 
use, according to the method of Ziemssen, a perfectly safe procedure 
in clean, i.e., aseptic, hands. Landois made use of the fact that blood 
does not clot in the body of leeches in preparing a decoction of leech 
heads with 0. 6 per cent of common salt, and Wright made use of the 
fact that blood does not clot in the presence of certain salts to receive 
it as it flows in a solution of sodium oxalate to keep it thin. By these 
methods the troublesome operation of defibrination is avoided. In 
no case may heterogeneous blood — i.e., blood from a different ani- 
mal — be used in the body of man. 



NOTES. 



Sycosis (p. 1-4). For every-day use : 

R Acidi tannici 2.0 

Sulphur praecipitatis 4.0 

Zinci oxidi, 

Amyli aa 7.0 

Vaselini 20.0 

M. S. Apply daily. 

To destroy the parasite : 

R Sublimati 1.0 

Spiritus vini gallici 99.0 

M. S. Dab the surface with cotton morning and evening, after epilation. 

Bacteria, selective action of (p. 64) ; used as destructive agents. 
Loffler exterminated the field mice, which multiplied to constitute 
a plague in Thessaly, by feeding them with the Bacillus typhi mu- 
rium, a micro-organism innocent to all other animals. 

Hydrophobia, treatment of (p. 103). Blasi and Travati find 
that lemon juice most quickly neutralizes the poison of hydrophobia. 
Thus lemon juice destroys it within three minutes, creolin in one-per- 
cent solution in three minutes* etc. Carbolic acid is one of the 
feeblest agents, as a five-per-cent solution requires fifty minutes, a 
three-per-cent solution one hour. 

Influenza. Salipyrin (p. 122) is not a real specific, and there is 
no specific. Salipyrin acts only as an antineuralgic and antifebrile — 
i.e., as a symptomatic remedy (Furbringer). Children are very 
rarely affected, and always later than adults (Baginsky). 

Tuberculosis (p. 147). The hectic fever is not caused by the 
tubercle bacillus, but by the streptococcus. Koch calls the see-saw 
hectic temperature record the " streptococcus curve." 

Agaricin in night sweats of tuberculosis (p. 156). Agaricin 
acts slowly, not before five hours, but as long as for twenty-four 
hours. It should be given, therefore, early, at 5 p.m., in a pill or in 
syrup. 



800 NOTES. 

Syphilis (p. 174). Pigmented syphilides. 

R Corrosive sublimate, 

Salol ,aa 1 part. 

Alcohol 100 parts. 

Bergamot (or geranium) oil enough to perfume. 

Kub the spots with this solution daily, and let them dry without 
wiping. When they have become a little attenuated bathe them 
lightly with the following lotion : 

R Glycerin, 

, Rose water aa 25 parts. 

Borax 2 " 

Corrosive sublimate solution 1 : 1000 10 " 

Later on apply the following dusting powder : 

R Talc, powdered, 
Zinc oxide, 
Camphor, powdered, 
Salol aa equal parts. 

Itching. — A fine preparation for relief of itching after measles, 
scarlet fever (p. 216), etc., is that of Klein: 

R Lanolini purissimi (Liebreicb) anhydrici 50.0 

Vaselini puri 20. 

Aquae destillatse 25.0 

Misce terendo; fiat unguentum. S. Apply every three hours. 

The evaporation of the water cools the surface and thus lessens the 
hypersemia of the cutis. 

Ear Furunculosis after scarlet fever, etc. (p. 217). Cholewa 
finds by far the best remedy is menthol, a ten-per-cent solution in 
oil. Apply with cotton, which is inserted and allowed to remain. 
The pain is relieved on the day of application, as the vapor of men- 
thol kills the micro-organisms. Continue the treatment for eight 
days to prevent recurrence. 

Diphtheria. A streptococcus (p. 247), whose virulence was 
tested in every way, was found by Landmann in the well-water which 
supplied five families in the suburbs of Frankfort. Three of five 
cases in these families died of diphtheria which developed from a 
streptococcus angina evidently introduced by the drinking-water. 

Diphtheria, Blood Serum Therapy (p. 252). Behring claims 
to secure both immunity and cure of pure diphtheria by inoculation 
with the blood serum of animals — dogs and sheep — rendered immune 
to diphtheria. The animals are rendered immune by injection of 
diphtheritic matter of gradually increasing virulence. The serum is 



NOTES. 801 

prepared and preserved with 0. 6 per cent carbolic acid ready for use. 
It is perfectly innocuous in the dose of 1 gramme per day for every 
kilogramme of body weight. Experiments upon animals yield per- 
fect results. Diphtheria in man is, however, not a pure process. It 
is usually complicated with sepsis — i.e., streptococcus infection, upon 
which the blood serum has no effect. Nevertheless in all the cases 
thus far reported the mortality has been reduced from sixty to 
twenty per cent. 

Typhoid Fever, perforation of intestine (p. 284). Of 12 cases 
thus far operated upon but 1 recovered (Freyhaus). 

Gastro-intestinal Catarrh op Infants (p. 361). Of 1,000 
cases of death from summer diarrhoea Hope found but 30 that had 
been fed exclusively at the breast, and Meinert found but 21 of 602. 
Meinert and Seibert showed that diarrhoea begins at 60° F. , and be- 
comes epidemic when the mean daily temperature does not fall below 
this degree. 

Alimentation per Rectum (p. 395). Maragliano reported a 
case where a patient was fed exclusively by the rectum for ninety- 
four days and ultimately recovered . At the end of that time she 
was found to have lost only 2. 7 kilogrammes (6 pounds avoirdupois) 
in weight. The nutrient enemata employed in this case were pre- 
pared as follows : 300 grammes (10 ounces) of beef and 150 grammes 
(5 ounces) of pancreas were pounded together in a mortar and the 
juice strained. To this were added 5 grammes (75 grains) of sodium 
carbonate, 25 grammes (6 fTuidrachms) of fresh ox bile, and water a 
sufficiency. The enema was administered in four portions in the 
course of the day, with a sufficient quantity of warm water. This 
formula differs from that recommended by Leube only in the addi- 
tion of ox bile — a modification introduced by Sciolla for the purpose 
of stimulating absorption of the enema by the large intestine and of 
preventing putrefactive decomposition. 

Stomach Tube. In the introduction of the stomach tube (p. 369) 
always push it in the throat to the left to follow the entrance of the 
oesophagus. 

Stomach. Hyperacidity of the gastric juice (p. 375) is shown 
whenever it requires more than 0.65 liquor potassse to neutralize 10 
cubic centimetres of gastric juice. 

Occlusion op Intestine (p. 133). Spontaneous cure, accord- 
ing to the latest reports, is more frequent than is commonly believed. 
Thus Goldtdammer saw 15 recoveries in 50 cases treated wholly on 
the expectant plan. 
51 



802 NOTES. 

Biliousness (p. 475). The liver protects the body against auto- 
intoxication. This antitoxic is one of the chief functions of the liver. 
Poisons are introduced into the intestine with the foods (alkaloids, 
potash salts, alcohol, etc)., or as products of the action of micro-or- 
ganisms, ptomaines, toxines, toxalbumins. Material is brought also 
by the blood for the formation of bile, urea, etc. The liver in health 
disinfects and purifies all these matters. Slight interference with this 
action of the liver produces the discomfort and distress of "bilious- 
ness " ; abolition of action produces the ominous signs of icterus 
gravis. 

Pleurisy (p. 543). Serum free of bacteria is usually the result 
of tuberculosis. The effused serum may contain so few bacilli that 
a syringeful may fail to inoculate a healthy guinea-pig, but may 
produce in a tuberculous guinea-pig the characteristic reaction of 
tuberculin. 

Myxcedema (p. 589). Different views have recently tended to 
unite in the belief that the three processes — strumous cachexia, 
myxcedema, and cretinism — have the same original cause. All cases 
seem to be due to the absence of the thyroid gland. In the examina- 
tions of 13 cretins at the Salkammergut, 10 were found in whom 
more or less large tubercles of the thyroid were seen, and 3 in whom 
no trace of a thyroid gland was found in the neck. 

Arterio-capillary Sclerosis (p. 590). Alanus advances the 
view that this condition is due to a too exclusive vegetable diet. He 
observed it in himself — a young man, not yet forty years of age, and 
not addicted to alcohol — in the temporal and radial arteries. Ray- 
mond saw it in a number of young monks, vegetarians, and Treille 
remarked it of the inhabitants of Bombay and Calcutta, who live 
largely on rice. According to Gabler the mineral salts in the vege- 
tables come to be deposited in the walls of the blood vessels. 
"Vegetable food injures the blood vessels and precipitates the 
changes of age." 

Larynx Tuberculosis (p. 489). Siemen strongly recommends 
the inhalation of iodoform according to a formula which masks the 
evils (odor) but preserves the curative effects. Thus : 

B Iodoformi gr. xv. 

Olei eucalypti .'■-„ . . ... . . . 3 vi. 

Olei caryophilli 3 i., gtt. xv. 

Alcohol absoluti. gtt. ij . 

M. Pour ten to fifteen drops upon oil of turpentine and inhale three or four 
times a day. 

Gonorrhoea (p. 179). The view that gonorrhoea is only a local 



NOTES. 803 

process is much modified by the actual discovery by Leyden of the 
gonococcus upon the valves as the cause of a verrucose endocarditis. 
Abbott recommends for the purpose of obtaining a good double 
staining of gonococci the following method : A drop of suspected 
pus is smeared upon the surface of a cover glass, and after drying 
is treated with a strong (twenty -per-cent) solution of tannic acid. It 
is then washed in alcohol, and after drying stained with Ziehl's solu- 
tion of fuchsin. It is next decolorized in acid alcohol (acetic acid 1, 
alcohol 100 ; or hydrochloric acid 1, alcohol 500), and after drying 
restained with methylene green, washed in water, dried, and mounted 
in balsam. The protoplasm of the cells appears of -a light-green 
color, the nuclei purple, and the diplococci a dark red. 

Bubo. Wielander's abortive treatment : Inject into the bubo 
fifteen drops of a one-per-cent solution of the benzoate of mercury in 
two places. As many as seventy-three per cent of cases undergo 
resolution under this treatment, including indolent buboes six 
months old, previously treated in vain by incision and every other 
way. In some cases suppuration ceased even after it had begun. 

Chlorosis, anaemia, etc. (p. 603). Iron in the form of haemo- 
globin is ingested with the common, so-called blood sausage. 

Pernicious Anemia (p. 604). The view gains ground that 
many cases are due to helminthiasis — especially to the fish tape- 
worm. Wiltschur reports the actual finding of tapeworms in 5 of 30 

cases. 

Hydrops (p. 653). Puncture in relief of, should be done only in 
the legs, never in the scrotum, with the aseptic precautions mentioned. 
The leg should then be enveloped in thick layers of absorbent 
cotton. A piece of three-per-cent carbolized, or one-half -per-cent 
sublimated, i.e., sterilized, gauze should be applied over each 
puncture. 

Hematuria (p. 666). To determine if blood comes from the 
kidney or bladder, Ultzmann washes out the bladder and injects into 
it a solution of potassium iodide (1.5 per cent). The saliva is now 
tested for iodine, which, if found, indicates a break in the bladder, 
as the sound bladder does not absorb it. 

Cystitis (p. 672). Marsh highly recommends oxalic acid as a 
sedative, which, he says, relieves the worst symptoms at once : 

R Acidi oxalici 0.95 

Syrupi aurantii corticis 80.0 

Aquae destillatse 120.0 

M. S. Coffeespoonful every four hours. 



804 NOTES. 

The Cancer Parasite (p. 67). "The cancer parasite must 
stand very near to the sporozoa. It certainly does not belong to the 
coccidia, nor to the sarco-, micro- or myxo-sporidia. Most likely it 
will be found among that variety of the sporozoa which Aime Schnei- 
der long ago distinguished as the amceba-sporidia" (Ludwig Pf eiffer, 
Centralblatt fur Bakteriologie, etc., August 1st, 1893). 

Creosote in Tuberculosis (p. 151). The virtue of creosote 
depends chiefly upon the fact that it inhibits the growth of the micro- 
organisms of secondary infection without injuring the stomach. 
Thus, while a saturated aqueous solution, it does not destroy the 
tubercle bacillus in cultures in twelve hours (Sternberg) ; and while 
rabbits inoculated with tuberculosis and treated with creosote sub- 
cutaneously presented the same lesions as control animals not so 
treated (Trudeau) ; further, that in the proportion of 1 : 100 it fails, 
after twenty hours' exposure, to destroy tubercle bacilli in the spu- 
tum (Cornet), nevertheless it is fatal to ordinary micro-organisms 
in the proportion of 1 : 500 or 1 : 1000 (Wernicke, Buchholtz), with- 
out in the least interfering with the digestive action of the gastric 
juice. For, according to Brunton, while 1 part of chlorine in 8,540 
parts of a saturated solution will arrest the digestive action of ptya- 
lin upon starch paste, and corrosive sublimate is so enormously 
destructive as to arrest its action even in 1 part to 51,000, creosote 
has no action on ptyalin, even in saturated solution, and has but a 
very feeble action upon pepsin. Creosote should therefore be given 
internally, after meals, and not subcutaneously. 

Pertussis Death Rate (p. 114). The following diagram, accu- 
rately drawn to a scale by the American Practitioner, shows the 
relative number of the deaths mentioned in the State of Kentucky 
for the first year of this decade : 

DEATHS IN KENTUCKY, 1891. 
— ^— — _— «_ -«»>»- Consumption. 



Typhoid Fever. 



Diphtheria. 



■^— — Cholera Infantum. 
=— n= Measles. 
^— Scarlet Fever. 
- Whooping Cough. 

This record may be taken as a fair average, in the absence of any 
prevailing epidemic, for other States and other years. 

Neuralgia of the Trigeminus (p. 686). Seguin strongly re- 
commends aconitin in pill, each containing 0. 0003 gramme, two daily 



NOTES. 805 

for women, three for men. The number may be increased to twelve 
daily, or up to tolerance as evidenced by a feeling of coldness and 
numbness in the whole body. Cumulative effects do not occur. 
From a rich experience the author declares that but very few cases 
are not benefited and many are cured — that is, secure exemption for 
one to three years. In a dose of two pills per day aconitin reduces 
the pulse rate and arterial tension in Basedow's disease. 

Migraine (p. 687). After failure with every other means Weiss 
found that pressure upon the abdominal aorta at a point where pul- 
sation may be felt, midway between the xiphoid cartilage and the 
umbilicus, immediately arrested the most violent headache and hy- 
peresthesia in 23 cases. Unfortunately the distress returns after 
relief of the pressure, but all patients are grateful for the temporary 
relief. 

Solutol — cresol made soluble in water by the addition of an al- 
kali — has the highest commendation as a disinfectant (p. 79). One- 
fourth of a pint added to ten or fifteen pints of water (a watering- 
canful) makes the most penetrating, strongest, and quickest-acting 
disinfectant for walls, floors, etc. , which may be sprinkled from the 
can. 

Nocturnal Incontinence of Urine (p. 673). Gowers re- 
commends as the best remedy the perchloride of iron in large doses, 
gtt. xx. -xxx. three times a day. 

Singultus, nervous or hysterical (p. 762). Stella controls it 
with pilocarpine 0.10 in 10. G water, of which ten drops three or four 
times a day. It is not to be used in the acute hiccough which is 
such an ominous sign in many grave infections. 

Sulphonal in habitual use ma}' produce a cherry-colored urine 
(haemato-porphyrin) as a warning sign of saturation. 



INDEX 



Abscess, actinomycotic, 20 

brain, 753 

liver, 455 

lungs, 535, 536 

peripleuritic, 552 

retropharyngeal, 231, 256 

subphrenic, 553 
Acarus scabiei, 4 , 

folliculorum, 8 
Acetone, test for, in diabetes, 68 
Achorion Schonleinii, 9 
Acne mentagra, 14 
Aconitin in neuralgia of the trigeminus, 

804 
Acromegaly, 729 
Actinomycosis, 18, 19 
Acute ascending paralysis, 727 

atrophy of the liver, 473 

bulbar paralysis, 726 

rheumatism, 314 
Addison's disease, 616 
Adenoid tissue, 479 

in pharynx, 358 
Adrenals, disease of, 616 
iEgophony, 546 
Aerobes, 60 

Agaricin in night sweats of phthisis, 799 
Age and arteries, 737 

in diagnosis of stomach disease, 390 , 
Agraphia, 756 
Ague, 284 
Air in blood, 599 

in pleural sac, 550 
Albumin in blood, 598 
Albuminuria, 639, 655 
Alcohol in the liver, 464 

in typhoid fever, 283 
Alcoholic liver, 462 

neuritis, 690 
Alcoholism, 788 

and apoplexy, diagnosis, 741 
Alexia, 756 

Alimentation by the rectum, 801 
Alkalies in jaundice, 445 
Altitude and malaria, 286 
Amenorrhoea and tuberculosis, 144 
Amnesia, 756 
Amoebae coli, 400 

Amyl nitrite in angina pectoris, 586 
Amyloid degeneration, 657 



Amyloid liver, 476 
Amyotrophic lateral sclerosis, 719 
Anaemia, 601 

blood-sausage iron in, 803 

pernicious, 603, 803 

splenic, 610 
Anaerobes, 60 
Anarthria, 765 

Anchylostoma duodenale, 44, 412 
Aneurism and tuberculosis, 143 

filled by clot, 595 

of abdominal aorta, 593 

of aorta, 592, 594 

of brain, 751 

of femoral artery, 593 

of hypogastric artery, 533 
Aneurisms, miliary, in apoplexy, 737 
Angina, 356 

Ludovici, 361 

pectoris, 585 
Anhydrsemia, 597 
Aniline dyes, 60 
Anthracosis pulmonum, 540 
Anthrax, 81 

oedema, 84 
Antitoxines, 21, 65 

of pneumonia, 137 

of tetanus, 111 
Aorta, aneurism of, 592, 594 
Aortic insufficiency, 573 

diagram of, 572 

tracing of, 574 
Aortic obstruction, 575 

diagram of. 572 

tracing of , 575 
Aphasia, 656 
Aphonia, 149, 759 
Aphtha, 87, 352 

Bednar's, 353 
Apomorphia in measles, 148 
Apoplexy, 736 
Apparatus for relief of "writer's cramp, 

780 
Appendicitis, 417 
Appendix vermiformis, 418 
Argyll. Robertson sign in tabes, 714 
Arsenic in chorea, 769 

in malaria, 295 
Arteries and age, 737 
Arterio-sclerosis, 590, 802 



808 



INDEX. 



Arthritis deformans, 623 

deformans and gout, diagnosis, 622 

pauperum, 623 
Arthrospores, 59 

Artificial respiration, modes of, 532 
Ascaris lumbricoides, 38 
Ascending paralysis, acute, 747 
Asiatic cholera, 335 
Aspermatism, 676 
Asphyxia by drowning, 529 
Aspiration in pleurisy, 546 
Asthma, 505 

and tuberculosis, 143 

crystals, 510 
* spirals, 510 

Atactic paraplegia, 719 
Ataxia, Friedreich's, 716 

hereditary, 716 

locomotor, 711 
Atelectasis pulmonum, 528 
Atrophy, facial, 733 

hereditary, 733 

of liver, 470, 473 

progressive muscular, 719 
Atropia in epilepsy, 749 
Aura, epileptic, 744 
Avocation neuroses, 778 
Azoospermia, 676 

Bacilli, 56, 57 
Bacillus, anthrax, 82, 86 

diphtheria, 246 

glanders, 90 

Havaniensis, 62 

influenza, 119 

Kochii, 137, 140 

leprosy, 168 

leprosy, in blood, 601 

measles, 192 

pertussis, 113 

pneumonia, 58, 62, 126 

tetanus, 106 

tuberculosis, 62, 140, 164 

tuberculosis, in blood, 601 

typhosus, 269 
Bacteria, 3, 56, 799 
Bacteriology, abscess of lungs, 536 

anthrax, 82, 86 

bronchitis, 497 

chicken-pox, 241 

cholera, 336, 340 

diphtheria, 246, 247 

dysentery, 324 

glanders, 90 

influenza, 119 

intestinal catarrh, 399 

lepra, 168 

measles, 192 

myocarditis, 578 

pertussis, 113 

pleurisy, 543 

pneumonia, 58, 62, 126 

pneumonia, catarrhal, 522 

pyelitis, 667 

relapsing fever, 265 



Bacteriology, rheumatism, 315 

stomatitis, 351 

syphilis, 171 

tetanus, 106 

tuberculosis, 62, 140 

typhoid fever, 269 
Band-box note in emphysema, 520 
Basedow's disease, 586 
Basilar meningitis, 159 
Basophile cells, 600 
Baths, cold, in typhoid fever, 282 

hot, in nephritis, 645 

warm, in intestinal catarrh, 402 
Beard's method of general electrization, 

765 
Bedbug, 9 

Bednar's aphtha, 353 
Bed sores in myelitis, 708 

in typhoid fever, 276 
Bee stings, 9 
Beef, in dietary of stomach disease, 394 

tapeworm, 27 

tea, 394 
Bell's palsy, 693 
Beriberi, 690 
Berlin, small-pox in, 236 
Beverage grateful in fever, 281 
Big jaw, 18 
Bile, in blood, 599 

pathology, 441 

test in urine, 441 
Biliary cirrhosis, 472 
Bilious fever, 292 
Biliousness, action of liver in, 802 
Black vomit, 296 
Bladder affection in hysteria, 761 

inflammation, 670 
Blennorrhea, 179 
Blood corpuscles, alterations of, 599 

corpuscles in urine, 665 

diseases of, 597 

examination of, 597, 600 

in leukaemia, 609 

in stools, 399, 408 

ingredients of, 598 

parasites, 600 

serum therapy in diphtheria, 800 

sweating of, 611 

Teichmann's test, 382 

transfusion of, 798 

vessels, disease of, 390 

vessels, filarise in, 53 
Blue births, 576 

fingers in Morvan's disease, 730 
Body lice, 7 
Bone and joint tuberculosis, 165 

caries and amyloid degeneration, 659 

changes in rickets, 629, 630 
Borax in epilepsy, 749 
Boston, small-pox in, 235 
Bothriocephalus latus, 29 
Bowels, haemorrhage from, 412 

obstruction of. 429 
Bradycardia, 582, 583, 584 
Brain abscess, 753 



INDEX. 



Brain, localization of lesions, 755 

symptoms in lead poisoning, 787 

tumor, 750 
Breath, bad, 395 
Bright's disease, 643 

and gastric catarrh, 365 

in scarlatina, 209 
Bromides in epilepsy, 749 
Bronchial asthma, 505 

casts, 498 
Bronchiectasis, 500 
Bronchitis, 489 

capillary, 493 

chronic, 495 

croupous, 498 

putrid, 497 
Broncho-pneumonia, 521 
Bronchorrhoea, 496 
Bronze-skin disease, 616 
Brown-Sequard's paralysis, 731 
Bubo, 181 

abortive treatment of, 803 
Bulbar paralysis, 725, 726 
Burns, treatment of, 786 

Cachexia, in stomach disease, 391 

malarial, 294 
Csecum, inflammation of, 417 
Calcified trichinae, 47 
Calculus, renal, 663 

Calf, enlargement of, in progressive at- 
rophy, 732 
Calomel in heart disease, 577 
Cancer, and gall stones, 453 

of the brain, 750 

of the intestine, 434 

of the larynx, 486, 488 

of the liver, 476 

of the lung, 539 

of the oesophagus, 359 

of the stomach, 377 

protozoa of, 67, 804 
Capillary bronchitis, 493 
Caput medusae, 467 

obstipum, 691 
Carbol-fuchsin solution, 60 
Carbonic acid poisoning, 798 

acid poisoning in croup, 255 

oxide poisoning, 797 
Carbuncles, metastatic, 84 
Casts, bronchial, 498 

in the urine, 640, 645, 650 
Cataract in diabetes, 681 
Catarrh, and rheumatism, 313 

gastric, 363 

intestinal, 397 

laryngeal, 483 

naso-pharyngeal, 357 
Catarrhal pneumonia, 161, 521 
Catarrhus sestivus, 122 
Cavities in the spinal cord, 729 
Cellular pneumonia, 522, 523 
Cercomonas intestinalis, 400 
Cerebral haemorrhage, 736 
Cerebro-spinal meningitis, 301 



Cerebellum, localization in, 757 
Cerebrum, localization in, 756 
Chalicosis pulmonum, 540 
Chancre, 172 

soft, 178 
Chancroid, 178 
Charbon, 81 
Cherry stones in appendix vermif ormis, 

422 
Chest expansion limited in pleurisy, 544 
Chicken-pox, 240 
Chilblains, 784 
Children, malaria in, 291 
Chlorides in urine absent in sastralgia, 
376 

in urine of pneumonia, 130 
Chlorine, poisoning by, 797 
Chloroform breath in diabetes, 631 
Chlorosis, 606 

iron in, 803 
Choked disc in brain tumor, 752 
Cholelithiasis, 446 
Cholera, Asiatic, 335 

infantum, 343 

morbus, 343, 397 

nostras, 343 

sicca, 339 

typhoid, 338 

typhoid, in yellow fever, 299 
Cholerine, 338 

Cholesteatoma of the brain, 751 
Cholesterin in gall stones, 448 
Chorea, 765 

adult, 769 

electrical, 769 

hysterical, 768 

magna, 758, 759, 769 

symptomatic, 767 
Chrysarobin in favus, 10 
Chyluria, 54 
Cimex lectularius, 9 
Circulation, disease of organs of, 554 
Cirrhosis, hepatis, hypertrophic, 469, 472 

of the liver, 462 

renal, 653 
Clap, the, 179 

Clasp-knife rigidity in spinal disease, 718 
Clavus hystericus, 760 
Claw hand in progressive atrophy, 721 
Climate in tuberculosis, 153 
Clothes lice, 7 

Clubbed fingers in tuberculosis, 150 • 
Coal dust in the lungs, 540 

smoke, analysis of, 797 
Cocaine, in haemophilia, 614 

poisoning by, 792 
Coccidia, 66 
Coccyodynia, 687 
Coffee- ground vomit in cancer of the 

stomach, 382 
Cold, extreme, effects of, 782 

bath in typhoid fever, 282 
Colic, lead, 787 
Colon, cancer of, 434 
Coma in diabetes, 681 



810 



INDEX. 



Coma in gastrectasia, 386 

in yellow fever, 299 

malarial, 293 

vigil, 274 
Comma bacillus of cholera, 336 
Concealed haemorrhage, 415 
Condurango in diseases of the stomach, 

370 
Congelation, 782 
Conjugated deviation of the eves, 740, 

756 
Constipation, 429 
Consumption, 137 
Contractions in hysteria, 760 
? Convulsions, epileptic, 742, 746 
Coprostasis, 429, 433 
Coqueluche, 112 
Cor bovinum, 574 
Cord, spinal, diseases of, 707 

spinal, gliomatosis of, 729 

spinal, haemorrhage of, 728 
Corpulence, 633 

Corpuscles, blood, alterations in, 599, 605 
Corymbose eruption of variola, 225 
Coryza, 478 
Cow-pox, 234 

Cows, foot and mouth disease of, 88 
Crab lice, 7 
Cramp, writer's, 778 
Cranium, syphilitic necrosis of, 175 
Creolin, in erysipelas, 81 

-ichthyol solution, 481 
Creosote, action of, 804 

in tuberculosis, 154, 804 
Cretinism, 802 
Croup, 253 

false, 256 
Croupous bronchitis, 498 

pneumonia, 124 
Cry, epileptic, 745 
Cryptogenetic sepsis, 70 
Cryptorchism, 676 
Crystals, asthma, 510 
Culture soils, 61, 62 
Curschmann's crystals, 510 
Cyanosis, 349 
Cysticercus cellulosae, 25, 26, 27 

of the heart, 581 
Cystine kidney stones, 664 
Cystinuria, 664 
Cystitis, 670 

oxalic acid in, 803 

Dance, St. Vitus', 765 
Deafness, sudden, in mumps, 189 
Degeneration, amyloid, 657 

reaction of, 693 
Delirium tremens, 790 
Dementia paralytica, 774 
Dermatomycoses, 9 
Diabetes insipidus, 683 

mellitus, 677 
Diabetic coma, 681 
Diamine, 664 
Diaphragm, spasm of, 513 



Diarrhoea, 398 

Diathesis, hemorrhagic, 611 

Diet, in diabetes, 682 

in diseases of the stomach, 370, 392 

in tuberculosis, 155 
Digitalis, in dropsy of nephritis, 652 

in heart disease, 577, 587 

in tetany, 735 
Dilatation of stomach, 385 
Diphtheria, 244 

and scarlatina, diagnosis, 210, 211, 
250 

blood serum therapy in, 800 

streptococcus in drinking-water, 800 
Diphtheritic paralysis. 248 
Diplococcus pneumonia?, 127 

in sputum, examination of, 135 
Dipsomania, 792 

Disinfection of walls, etc., 79, 809 
Disposition to disease, 64 

to tuberculosis, 143 
Distoma haematobium, 55 

hepaticum, 54, 412 
Dittrich's plugs, 497, 538 
Diuretin in dropsy of nephritis, 652 
Dog tapeworm, 34 
Dogs and rabies, 97 
Drinking-water, purity of, 393 
Dropsy, in heart disease, 577 

in kidney disease, 640, 650, 653 

puncture in relief of, 803 
Drowning, 529 

Dwarf corpuscles in blood, 599 
Dysentery, 323 

Dysmenorrhoea and tuberculosis, 144 
Dyspepsia, 363, 376 

and tuberculosis, 144 

in helminthiasis, 29 
Dystrophy, juvenile, 732 

progressive, 731 

Ear affection in leptomeningitis, 703 

in scarlatina, 208 

disease in abscess of brain, 753 

furunculosis of, 800 
Echinococcus, 34 

multilocularis, 37 

of the lungs, 540 
Eclampsia from lead poisoning, 787 
Ectozoa, animal, 4 

vegetable, 9 
Eczema, 11 

marginatum, 13 

from pediculi capitis, 6 

from pediculi vestimenti, 7 

from scabies, 4, 5 
Effusion, forms of, in pleurisy, 544 

in pericarditis, 559 
Egg in dietary of stomach disease, 393 
Ehrlich's solution, 60 
Elastic tissue in sputum, 151, 152 
Electricity in facial paralysis, 696 

in gastralgia, 389 
Elephantiasis from filaria sanguinis, 53 

Graecorum, 167 



INDEX. 



Sll 



Emboli, pulmonary, and asthma, 513 
Embolism, fatty, 598 

of the lungs, 534 
Embolus and haemorrhage, 741 
Emphysema, and tuberculosis, 143 

of the lungs, 518 
Empyema, 547 
Endarteritis obliterans, 176 
Endocarditis, 563 

and pericarditis, 561 

produced by gonorrhoea, 802 

sclerotic, 569 

septic, 567 
Endospores, 59 
Enemata. nutrient. 395, 411 
English disease, rickets, 628 
Enteralgia, 688 
Enteric fevers, 268 
Enteroclysters in cholera, 342 
Enterorrhagia, 408, 411 
Entozoa, 23 
Enuresis, 672 

Eosinophile cells, 600, 605, 609 
Epidemic cerebro-spinal meningitis, 301 
Epididymitis, 181 
Epilepsy, 742 

and hysteria, 748, 758 

and palpitation of the heart, 583 
Epithelium in urine of nephritis, 649 
Erysipelas, 72 

marginatum, 77 

migrans, 77 

and vaccination, 239 
Erythema in variola, 220 
Essential anaemia, 603 
Exophthalmic goitre, 586 
Extremities, gangrene in Raynaud's dis- 
ease, 730 
Eye affection, in Bright's disease, 648 

in endocarditis, 568 

in tabes dorsalis, 714 

in small-pox, 227 
Eyes, conjugated deviation of, 740, 756 

protrusion of, in Basedow's disease, 
587 

Facial atrophy, 733 

palsy, 693 
Faeces, bacteria of, 400 

under the microscope, 400 
Farcy, 90 

buds, 92 
Fasting girls, 761 
Fat, excessive, 633 

in blood, 598 

in undigested food, 399 
Fatty embolism, 598 
Fauces, diseases of, 349 
Favus, 9 

scutulum, 10 
Feet, paralysis of, in neuritis, 69 
Fermentation test for sugar, 679 
Ferments, 3 

Fern, male, in tapeworm, 33 
Fetid bronchitis, 497 



Fever and ague, 284 
Fibrin in blood, 598 
Fibrinous bronchitis, 498 
Fibroid tumor of the larynx, 486 
Filaria Bancrofti, 52 

Medinensis. 52 

sanguinis, 52 
Fingers, deformity of, in Morvan's dis- 
ease, 730 
Fish tapeworm, 29 
Flea, the common, 9 

sand, 9 
Flies and anthrax, 83 
Flux, 323 

Fog in protection against asthma, 508 
Foot and mouth disease, 87 

hysterical contraction of, 760 

perforating ulcer of, 690 
Foreign bodies in appendix vermif ormis, 

421 
Fracture, green-stick, in rickets, 630 
Frankel's bacillus of pneumonia, 126 
Freaks of hysteria, 761 
Freezing, 782 
Fremitus, hydatid, 36 
Friedlander's pneumococcus, 126 
Friedreich's ataxia, 716 
Fright as cause of epilepsy, 744 
Frost bites, 784 

bites and Raynaud's disease, 731 
Fungi, 3 

mould, from abscess of lungs, 536 
Fungus, actinomyces, 18 

disease of India, 15 

thrush, 17 
Furunculosis, in diabetes, 681 

of the ear, 800 

Gabbett's stain of tubercle bacillus, 601 
Gait, in lateral sclerosis, 718 

in paralysis agitans, 771 
Gall, stones, 446 

as cause of jaundice, 444 

as cause of occlusion of intestine, 431 
Gangrene, in diabetes, 681 

of extremities in Raynaud's disease, 
730 

of the lungs, 537 
Gastralgia, 387, 688 

and gall stones, diagnosis, 452 

and hysteria, 388 
Gastrectasia, 385 
Gastric catarrh, 363 

catarrh of infants, 801 

juice, hyperacidity of, 801 

ulcer, 372 
Genito-urinary system, disease of, 637 
Gin drinkers' liver, 462 
Glanders, 90 
Glioma of the brain, 750 
Gliomatosis of the cord, 729 
Globus hystericus, 359, 759 
Glossitis, 349 

Glosso-labio-laryngeal paralysis, 725 
Glottis, cedsma of, 485 



812 



INDEX. 



Glottis, spasm of, 759 
Glycosuria, 677 
Goitre, acute, 590 

exophthalmic, 586 
Gonococcus, 180, 182 

double stain for, 8Q3 
Gonorrhoea, 179, 802 

as cause of cystitis, 671 
Gonorrhceal rheumatism, 320 

threads in urine, 184 
Gothard worm, 44 
Gout, 618 

and gravel, 665 

rheumatic, 623 
4 Gouty fingers, 620 
Gram's solution, 61 
Grand mal in epilepsy, 744 
Grandeur, ideas of, in dementia, 775 
Gravel, and gout, 665 

renal, 663 
Graved disease, 586 
Green sickness, 606 

soap in vertebral caries, 167 
Grip, the, 118 
Guinea worm, 52 

Habitus, of lateral sclerosis, 718 

phthisical, 143 
Haematemesis, 376 

in cirrhosis hepatis, 466 
Haemathidrosis, 611 
Haematoma of the dura mater, 696 
Haematomyelia, 728 
Hsematopericardium, 563 
Haematorrhachis, 728 
Haematothorax, 552 
Hematuria, 54, 292 

in nephritis, 645 

red blood corpuscles in, 665 

source of, how to determine, 803 
Haemin crystals, 382 
Haemoglobin, 598 

in blood sausage, 803 

in chlorosis, 607 
Hasmoglobinaemia, 599, 612 
Haemophilia, 613 
Haemorrhage, cerebral, 736 

concealed, 408, 415 

from cirrhosis hepatis, 466 

from gastric ulcer, 376 

of the bowels, 408, 412 

in typhoid fever, 273, 274 

in variola, 223 

in yellow fever, 300 

spinal, 728 
Hsemorrhagic diathesis, 611 

infarction of the lungs, 534 
Hair in favus, 11 

in herpes tonsurans, 13 
Hairy hearts. 554 
Hand, claw, in progressive atrophy, 721 

deformity in acromegaly, 729 

obstetric habitus in tetany, 734 

posture in paralysis agitans, 770 
Hay asthma, 122 



Hay fever, 122 

Headache, 687 

Heart, affection of, in typhus, 261 

cysticercus of, 581 

degeneration of, in typhoid fever, 276 

disease of, 554 

disease and asthma, 512 

disease and rheumatism, 317 

disease and tuberculosis, 143 

failure, 578 

failure in bronchitis, 496 

failure in pneumonia, 134 

hypertrophy in nephritis, 642, 655 

muscle, inflammation of, 577, 579 

neuralgia of, 585 

neuroses of, 581 

palpitation of, 582 

palpitation of, in Basedow's disease, 
586 

syphilis of, 581 

topography of, 583 

tuberculosis of, 581 
Heatstroke, 780 
Hegar's method of irrigation of the bowel, 

427 
Heller's test for blood-coloring matter, 

382 
Hemianaesthesia, 756 
Hemianopsia, 756 

Hemiparaplegia, Brown-Sequard ; s, 731 
Hemiplegia alternans, 726 

cruciata, 726 

in apoplexy, 739, 740 
Hepatalgia and gastralgia, 389, 452 
Hepatitis, interstitial, 462 

suppurative, 455 
Hepatotomy in abscess of the liver, 461 
Hereditary ataxia, 716 

atrophy, 733 

syphilis, 171 
Herpes circinatus, 12 

in cerebro-spinal meningitis, 304 

indications of, 349 

in pneumonia, 130 

tonsurans, 12. 13 
Hiccough, pilocarpine in, 805 
Hobnail liver, 462 
Hodgkin's disease, 610 
Homines quadrati in apoplexy, 737 
Hooklets of echinococcus, 35 
Hornet stings, 9 
Howard's method of artificial respiration, 

533 
Humidity and malaria, 286 
Hunger and predisposition to disease, 64 
Hydatid fremitus, 36 

tapeworm, 34 
Hydraemia. 597 

and immunity, 64 
Hydrochloric acid free in cancer of the 
stomach, 383 

acid in gastric juice, 368 
Hydronephrosis, 669 
Hydropericardium, 563 
Hydrophobia, 96 



INDEX. 



813 



Hydrophobia, lemon juice in, 799 

Hydrothorax, 546, 551 

Hyper- and Hypalbuminosis, 598 

Hyper- and Hypinosis, 598 

Hyperaesthesia in cerebro-spinal menin- 
gitis, 303, 306 

Hyperpyrexia in rheumatism, 317 

Hypertrophic cirrhosis of the liver, 469, 
472 

Hypertrophy, pseudo-, of muscle, 731 

Hypochondriasis, 763 

Hypodermatic clysters in cholera, 343 

Hypostatic pneumonia, 526 

Hysteria, 359, 757 

and epilepsy, diagnosis, 748, 758 
and gastralgia, 388 

Hysterogenic spots. 760 

Icterus, 439 

gravis, 802 

in intestinal catarrh, 398 

in remittent fever, 292 

in yellow fever, 299 

neonatorum, 440 
Ileo-typhus fever, 268 
Ileus, 427 
Immunity, 64, 65 
Impotence, 675 

in diabetes, 680 

in diphtheria, 249 

in tabes, 714 
Incontinence of urine, 672, 805 
India fungus, disease of, 15 
Indian cholera, 335 
Indican, in intestinal occlusion, 433 

in typhlitis, 423 

test for, 433 
Indigo kidney stone, 664 
Infantile paralysis, 722 
Infants, gastro-intestinal catarrh in, 801 
Infarct, uric-acid, in new-born, 665 
Infarction, haemorrhagic,of the lungs, 534 
Infections, 3, 63 
Infectious diseases, 68 
Influenza, 118 

action of salipyrin in, 799 
Infraspinatus, atrophy of, in pseudo- 
hypertrophy, 732 
Infusoria, 66 

Ingravescent apoplexy, 739 
Inosite in echinococcus cysts, 37 
Insane, progressive paralysis of, 774 
Insolation, 780 
Insomnia in delirium tremens, 791 

in trichinosis, 50 
Intercostal neuralgia, 686 
Intermittent cerebro-spinal meningitis, 307 

fever, 284, 289, 290 
Intestine, neuralgia of, 688 

occlusion of, 801 
Intestinal catarrh, 397 

haemorrhage, 44 

occlusion, 429 

protozoa, 400 

ulcer, 403 



Intestinal worms, 23 
Intoxication, 63 
Intubation in croup, 256 
Intussusception, of intestine, 431 

and dysentery, 331 
Invagination of the intestine, 431 
Iodine-potassium-iodide solution, 60 
Iodoform, in erysipelas, 81 

gauze in haemorrhage, 614 

in laryngeal tuberculosis, 802 

in sepsis, 71 
Iodoformol in bone tuberculosis, 166 
Ipecac in dysentery, 333 
Iron dust in the lungs, 541 

subsulphate in diphtheria, 251 
Irrigation of the bowel in dysentery, 332 

in jaundice, 445 

in treatment of threadworm, 43 
Itch, 4 

Itching, after measles, etc., treatment of, 
800 

in jaundice, 442 

Jaundice, 439 

in cirrhosis of the liver, 467 

in intestinal catarrh, 398 

in remittent fever, 292 

in yellow fever, 299 

simulation of, 442 

with gall stones, 451 
Jaw, big, actinomycosis, 18 
Jejunum, catarrh of, 399 
Joints, neuralgia of, 688 
June cold, 122 
Juvenile dystrophy, 732 

Kakke, 690 

Keratin pills in gastric digestion, 387 

Kidney, acute inflammation of, 643 

affection in scarlatina, 209 

amyloid degeneration of, 657 

anosmia of. 643 

calculus, 663 

chronic inflammation of, 647 

cysts in, 669 

diseases of, 637 

epithelium, 649 

floating, 661 

gravel, 663 

hyperaemia of, 642 

interstitial inflammation of, 653 

pelvis, diseases of, 663 

sand, 663 

stone, 663, 670 

stone and gall stone, diagnosis, 453 

syphilis of, 661 

topography of, 661 

tuberculosis of, 155, 660 

uric- acid infarction in new-born, 665 

wandering, 661 
Knee jerk in diabetes, 680 

in diphtheria, 249 

in tabes, 714 
Krull's cold-water irrigation of jaundice, 
445 



814 



INDEX. 



Lactic acid, Uffelmann's test for, 369 
Landry's paralysis, 727 
Laparotomy, in occlusion of the intes- 
tine, 434 

in typhlitis, 428 

in typhoid fever, 284, 801 
Laryngeal glosso-labio-paralysis, 725 
Laryngismus stridulus, 256 
Laryngitis, catarrhal, 483 

tuberculous, 146, 486 
Larynx, cancer of, 486, 488 

catarrh of, 483 

diseases of, 481 

irritation of, as cause of asthma, 508 
X normal, and trachea, 482 

oedema of, 485 

paralysis of, 487, 488 

spasm of, in rickets, 631 

stenosis in measles, 195 - 

syphilis of, 488 

tuberculosis of, 486 

tumor of, 486, 488 
Lateral sclerosis, 717, 719 

sclerosis, amyotrophic, 719 
Lead poisoning, 786 

poisoning and gall stones, diagnosis, 
453 
Leontiasis leprosa, 168 
Lepra, 167 

bacilli in blood, 601 
Leprosy, 167 
Leptomeningitis, 703 
Leptothrix buccalis, 18 
Leube's four diet lists, 395 
Leucin in sputum of empyema, 548 
Leucocytes, emigrated, in hydrophobia, 99 
Leucocythaemia, 608 
Leucocytosis, 600 
Leukaemia, 608 
Lice, body, 7 

crab, 7 

head, 6 
Lime salts in rickets, 628 
Lip, furunculosis of, 85 
Lipomatosis in pseudo-hypertrophy, 733 
Liquor dealers, mortality of, 789 
Liver, abscess of, 455 

acute atrophy of, 473 

amyloid, 476 

antiseptic action of, 802 

atrophy of, 470 

cancer of, 476 

cells in yellow fever, 299 

cirrhosis of, 462, 469, 472 

diseases of, 439 

displaced by pericardial effusion, 560 

fatty, 475 

fluke, 54 

hyperemia of, 475 

syphilis of, 176, 470 
Lobular pneumonia, 521 
Localizations in the brain, 755 
Lockjaw, 105 
Locomoto^ataxia, 711 
Loffler's solution, 60 



Lues venerea, 169 
Lumbago, 322, 692 
Lumbricoid worms, 38 
Lungs, atelectasis of, 528 

cancer of, 539 

diseases of, 489 

echinococcus of, 540 

embolism of, 534 

emphysema of, 518 

gangrene of, 537 

inhalation of dust into, 540 

metastatic abscess of, 535 

oedema of, 527 

sarcoma of, 540 

syphilis of, 539 

test of expansion, uric acid, 665 
Lustgarten's syphilis bacillus, 171 

Macrocytes in blood, 599, 605 
Madura disease, 15 
Malaqua, 289 
Malaria, 284 

and cerebro spinal meningitis, 310 

and meningitis, 163 

Plasmodium of, 66 
Malarial cachexia, 294 

neuralgia, 292 
Malignant pustule, 81, 82 
Malum perforans pedis, 690, 715 
Mania a potu, 790 
Marsh and malaria, 286 
Marshall Hall's artificial respiration, 532 
Masked malaria, 292 
Masturbation, 674, 676 
Measles, 190 

and variola, 229 

French, 198 

German, 198 

noma in, 354 
Measly pork, 25, 27 
Meats in dietary. 394 
Medulla, sclerosis of, 725 
Megaloblasts, 600 
Melaneemia, 599 
Melsena neonatorum, 414 
Membrane of echinococcus, 35 
Meningeal haemorrhage, 728 
Meningitis, and malaria, 163 

and pneumonia, diagnosis, 135 

and typhoid fever, 163 

cerebro-spinal, 301 

in scarlatina, 212 

in variola, 228 

simple cerebral, 696, 703 

tubercular, 159 
Mercurial stomatitis, 349 
Mercury, for pediculi, 7 

in favus, 12 

in herpes tonsurans, 14 
Metal transfer of sensations, 761 
Metallic tinkling in pneumothorax, 551 
Metastatic abscess of lungs, 535 
Methylene blue in thrush, 18 
Micrococci, 56 

non-specific, in gonorrhoea, 183 



INDEX. 



815 



Micrococcus gonorrhoeae, 180 

of pneumonia in pleurisy, 543 
Microcytes in blood, 599, 605 
Micro-organisms, 3, 56 
Microsporon furfur, 14 

mmutissimum, 14 
Migraine, 687 

abdominal pressure in, 805 
Miliary aneurisms in apoplexy, 737 

tuberculosis, 164 
Milk, and tuberculosis, 144 

in dietary of stomach disease, 393 

in foot and mouth disease, 88 

leg, 595 

spots, pericardial, 555 
Milzbrand, 81 

Mind, state of, in tabes, 715 
Mitral insufficiency, 571 

insufficiency, diagram of, 571 

insufficiency, tracing of, 570 

obstruction, 572 

obstruction, diagram of, 571 

obstruction, tracing of, 573 

valve, proportionate affection of, 566 
Molluscum contagiosum, 67 
Monadines, 400 
Moore's test for sugar, 679 
Morbilli, 190 
Morbus Addisonii, 616 
Morpio, 7 

Morvan's disease, 730 
Mosquitoes, 9 
Mould fungi from abscess of the lungs, 

536 
Moulds, 31 

Mouse odor of f avus crusts, 10 
Mouth, disease of, 349 

breathers, 358 

wash, 615 
Mucus, nasal, 478 
Multilocular echinococcus cysts, 37 
Multiple neuritis, 690 

sclerosis, 772 

sclerosis and paralysis agitans, 771 
Mumps, 186 

metastatic, 186 
Murexide test, 663 
Muscle affection in dystrophy, 731 

fibre in faeces, 400 

septic infection of, 69 

trichina in, 47, 49 
Muscular atrophy, progressive, 719 

rheumatism, 321 
Mycoderma albicans, 15 
Myelitis, 707 
Myocarditis, 577 
Myotony, 691 

Myrtol in putrid bronchitis, 504 
Myxcedema, 589, 802 

Nails, biting, infection with round worms 

by, 42 
Naphthol in herpes tonsurans, 14 

in pityriasis, 15 

in scabies, 5 



Nasal catarrh, 478 
Nasopharyngeal catarrh, 357 
Nematoid worms, 38 
Nephritis, acute parenchymatous, 643 

chronic parenchymatous, 647 

interstitial, 653 

scarlatinal, 209 
Nephrolithiasis, 663 
Nerves, diseases of, 685 

tissue, injection of, 765 
Nervous system, diseases of, 685 
Neuralgia, 685 

malarial, 292 

occipital, 686 

of coccyx, 687 

of head, 687 

of heart, 585 

of intestine, 387, 688 

of joints, 688 

of spermatic nerve, 688 

of stomach, 688 

of sciatic nerve, 686 
Neurasthenia, 764 
Neuritis, 690 
Neuroses, of the heart, 581 

avocation, 778 
Neurosis, vaso-motor, Raynaud's dis- 
ease, 730 
Neutrophile blood cells, 600 
New-born, haemorrhage of the bowels of, 

414 
Nicotine poisoning, 795 
Nitrite of amyl in angina pectoris, 586 
Nitroglycerin in heart disease, 577 

in nephritis, 653 
Nodular rheumatism, 623 
Noma, 354 

in measles, 195 
Nose, catarrh of, 478 

diseases of, 478 

glanders in, 93, 94 

polypi in, 481 

relation of, to asthma, 508 

sunken bridge in syphilis, 174, 350 
Nummulation of blood corpuscles, 597 

609 
Nylander's test for sugar, 679 
Nystagmus in multiple sclerosis, 774 

Obesity, 633 

Obstetric hand in tetany, 734 
Obstruction of the bowels, 429, 801 
Occipital neuralgia, 292, 686 
Occipito-frontal rheumatism, 322 
Occlusion of intestine, 429, 801 
Odor, as cause of asthma, 507 

mouse-like, of favus crusts, 10 

of stools in diarrhoea, 399 
(Edema of anthrax, 84 

of the glottis, 485 

of the lungs, 527 
(Esophagus, diseases of, 359 
Oligaemia, 601 
Oligocythaemia, 599 
Onanism, 674, 676 



816 



INDEX. 



Onychomycosis, 10, 13, 14 
Opisthotonos, 105, 107 

in cerebro- spinal meningitis, 203 

in hysteria, 758 
Opium, in cerebro-spinal meningitis, 312 

poisoning by, 793 
Optic papilla in brain tumor, 752 
Orchitis, in mumps, 188 

syphilitic, 176 

tuberculous, 165 
Orexin as an appetiser, 396 
Orthotonos, 304 
Osteomalacia, 633 
Otorrhcea and meningitis, 703 
Oxalate of sodium, property of prevent- 
ing coagulation, 798 
Oxalic acid crystals. 664 

acid in cystitis, 803 

acid stones, 664 
Oxyuris vermicularis, 41 

Pachymeningitis, 696 
Palpitation of the heart, 582 

in Basedow's disease, 586 
Palsy, shaking, 770 

wasting, 719 
Papilloma of the larynx, 486 
Paracentesis abdominis in cirrhosis, 471 

thoracis, 542, 549 
Paralysis, 692 

acute ascending, 727 

agitans, 770 

bulbar, 725 

Brown-Sequard's, 731 

facial, 693, 694 

glosso-labio laryngeal, 725 

in abscess of the brain, 754 

in diphtheria, 248 

in dysentery, 329 

infantile, 722, 724 

Landry's, 727 

lead, 787 

of the larynx, 487,488 

progressive, of the insane, 774 

spastic spinal, 717 
Paralytic dementia, 774 
Paraplegia, ataxic, 719 

in spinal hemorrhage, 728 

spastic, 717 
Parasites, 31, 60 

blood, 600 
Paratyphlitis, 417 

Parenchymatous degeneration in ty- 
phoid fever, 275 
Parkinson's disease, 770 
Parotitis, 186 

in typhoid fever, 276 
Pasteur's treatment of hydrophobia, 104 
Pearl on the rose, 240 
Pearls, epithelial, 353 
Pediculus capitis, 6 

pubis, 7 

vestimenti, 7 
Pellagra, 719 
Pelletierine in tapeworm, 33 



Pelvis, kidney, disease of, 663, 667 
kidney, inflammation of, 667 
renal, epithelial cells of, 668 
Peptic asthma, 508 

ulcer, 372 
Perforation in typhlitis, 423 

in typhoid fever, 274, 284, 801 
Pericarditis, 554 

and endocarditis, diagnosis, 561 
and pleurisy, 557, 561 
Pericardium, syphilis of, 563 

tuberculous, 562 
Perichondritis, 479, 485 
Peripleuritic abscess, 552 
Peritonitis, 275, 436 
Perityphlitis, 417 

Permanganate of potash in thrush, 18 
Pernicious anaemia, 603, 605, 803 

malaria, 293 
Pertussis, 112 

mortality of, 804 
Petechiae in typhus fever, 260 

in variola, 220 
Petit mal of epilepsy, 746 
Pettenkofer's test for bile acids, 441 
Phagocytosis, 65 
Pharynx, diseases of, 349 
Pharyngo-nasal catarrh, 357 
Phlebitis, 595 
Phlegmasia dolens, 595 
Phlorglucin-vanillin test for hydrochlo- 
ric acid, 368 
test in typhoid fever, 276 
Phosphatic kidney stones, 664 
Phosphaturia, 674 

Phosphorus affection of the liver, 475 
Phosphorus in rickets, 632 
Phthisis, 137 

Physiognomy in tetanus, 107 
Pinworm, 4 
Piperazin, in gout, 623 

in kidney stones, 667 
Pityriasis versicolor, 14, 15 
Plasmodium of malaria, 66 
Plethora, 597 
Pleurisy, 542 

and pericarditis, 557, 561 
effusion of, 802 
suppurative, 547 
Pleurodynia, 322 
Plica polonica, 6 
Plumbism, 786 
Pneumococcus, 62, 540 
Pneumonia, 124 

and variola, 228 
catarrhal, 521 
catarrhal, in measles, 195 
cellular, 522, 523 
deglutition, 16 
hypostatic, 526 
sputum, examination of, 135 
Pneumopericardium, 563 
Pneumothorax, 550 
Podagra, 618 
Poikilocytosis, 600, 605 



IXDEX. 



817 



Poisoning by cocaine, 792 
by s:ases, 796 
by fead, 786 
by nicotine, 795 
by opium. 793 
Poliomyelitis, 722 
Pollen and hay fever, 123 
Poliomyositis, 51 
Polypanarthritis, 624 
Polypi, nasal, 481 

nasal, and asthma, 508 
Polysarcia, 633 
Polyuria, 683 

Pomegranate bark in tapeworm, 32 
Pork, measly, 25, 27 

tapeworm, 27 
Posture in infantile paralysis, 724 
Potassium iodide in asthma, 517 
Pott's disease, 165, 167 
Pox, small-, 218 
syphilis, 169 
Predisposition to disease, 64 

to tuberculosis, 143 
Prescription for amyloid kidney, 660 

for anaemia, 603 

for angina, 358 

for bronchitis, 501 

for cholera, 342, 343 

for cystitis, 672, S03 

for epilepsy, 750 

for erysipelas, 81 

for favus, 12 

for gargle, 354 

for gastric catarrh, 371, 372 

for gout, 623 

for herpes tonsurans, 14 

for intestinal catarrh, 402 

for leukaemia, 610 

for mouth wash in scurvy, 615 

for nephritis. 653 

for neuralgia, 692 

for pertussis, 118 

for pityriasis, 15 

for rheumatism, 318. 320 

for rickets, 632 

for scabies, 5, 6 

for septicaemia, 71 

for thrush, 18 

for tooth powder, 354 

for typhoid fever, 281 

for typhoid fever, diarrhoea in, 283 

for typhoid fever drink, 281 

for vellow fever, 300 
Proctitis. 401 
Progressive muscular atrophy, 719 

paralysis of the insane, f 76 
Prostatorrhoea, 674 
Protozoa, 31, 65 

in cancer, 67, 804 

in dysentery, 324 

in faeces, 400 

in herpes zoster, 67 

in malaria, 287 

in moliuscum contagiosum, 67 

in vaccinia and varicella, 67 



Protozoa in variola, 67, 220 
Pruritus, after measles, 800 

in diabetes, 681 

in jaundice, 442 

opii, 749 
Pseudo-angina pectoris, 585 

-hypertrophic paralysis, 731, 733 

-leukaemia, 610 
Ptomaines, 63 
Puerperal scarlatina, 203 
Pulex irritans, 8 

penetrans, 8 
Pulmonary arteries, thrombus of, 534 

emboli and asthma, 513 

valves, regurgitation of, 576 

valves, stenosis of, 576 
Pulse, sphygmographic tracing, 570 
Purpura haemorrhagica, 612 

simplex, 612 

variolosa, 224 
Pyaemia, 68 

in dvsenterv, 329 
Pyelitis, 667 
Pyelo-nephrosis, 677 

-phlebitis, 470 

• thrombosis, 470 
Pylorectomy, 394 
Pylorus, cancer of, 379 
Pyocardium. 563 
Pyrogallic acid, in favus, 12 

in herpes, 14 

Quinine in malaria, 295 
Quinsy, 257 

Rabies, 96 

Rachitis, 628 

Ray fungus, 19 

Raynaud's disease, 730 

Reaction of degeneration, 657 

Recrudescence in typhoid fever, 278 

Rectal alimentation, 395, 801 

Rectum, cancer of, 434 

Rectus, rigiditv of, in abscess of liver, 

459 
Recurrent fever, 266 
Refluent embolus, 458 
Relapses in typhoid fever, 277 
Relapsing fever. 266 
Relative insufficiency of tricuspid valve, 

575 
Remittent fever, 292 
Renal calculus, 663 

cirrhosis, 653 

gravel. 663 

sand. 663 

stone. 663, 670 
Ren mobile, 661 
Resorcin in favus, 12 
Respiration, artificial methods, 532 

diseases of organs of, 478 
Retinitis albuminurica, 648 
Retropharyngeal abscess, 361 
Rhachialgia m cerebro-spinal meningitis. 
306 



818 



INDEX. 



Rheumatic gout, 623 
Rheumatism, 313 

and endocarditis, 316, 565 

and gout, diagnosis, 622 

and pericarditis, 551 

and septicaemia, 71 

chronic, 318 

gonorrheal, 182, 320 

in scarlatina, 209 

muscular, 321 

nodular, 623 
Rhizopods, 66 
Rickets, 628 
Rigidity, in apoplexy, 740 

in epilepsy, 745 

in hysteria, 758 
Ringworm, 12 
Risus sardonicus, 107 
Roseola syphilitica, 172 
Rofeheln, 198 
Roundworm, 38 
Rubella, 198 

Saint Vitus' dance, 765 

Salicylic acid in rheumatism, 317 

Salipyrin in influeDza, 622, 799 

Salol as test for stomach digestion, 369, 

887 
Salpingitis, 165 
Salt, in the blood, 598 

necessity of, 393 
Sand, renal, 663 

Santonin in treatment of round worm, 41 
Saprophytes, 59 
Sarcinee, 58 
Sarcocele, 176 
Sarcoma of the lungs, 539 
Saturnism, 786 
Scabies, 4 
Scarlet fever, 201 

and diphtheria, 210, 211, 250 

and measles, diagnosis, 210 

in nephritis, 643 
Schizomycetes, 3 
Sciatica, 293, 686 
Sclerosis, arterio-, 590, 802 

general, 774 

lateral, 717 

multiple, 772 

of medulla, 725 

of tabes dorsalis, 712 
fSc'lerotic endocarditis, 569 
Scorbutus, 614 
:Scrofula, 165 
:Scurvy, 614 

Segments of tapeworm, 25, 31 
;Semen, abnormal discharge of, 673 
iSepsis, 68 

cryptogenetic, 70 
'.Septic endocarditis, 567 
Septicaemia, 68 
Septico -pyaemia, 68 
Serum therapy, in diphtheria, 800 

in tetanus, 111 
Shaking palsy, 770 



Shellfish and gastralgia, 388 
Sick-headache, 687 

relief by pressure upon abdomen, 
804 
Siderosia pulmonum, 540 
Simon's triangle in small-pox, 220 
Simulation of jaundice, 442 
Singultus, pilocarpine in, 805 
Sinking typhus, 301 
Skin, farcy buds in, 92 

in herpes tonsurans, 12 
Small-pox, 218 
Smoke, coal, analysis of, 797 
Snakebites and purpura, 612 
Sodium chloride, in blood, 598 

in echinococcus cysts, 36 

necessity of, 393 
Softening of the bones, 633 
Solutol as disinfectant, 805 
Soor, 15 
Spasm, 691 

in tetany, 733 

of the larynx, 631 
Spastic paralysis, 717 

paraplegia. 717 
Speech, in bulbar paralysis, 726 

in dementia, 776 
Spermatic nerve, neuralgia of, 688 
Spermatorrhoea, 673 
Spermatozoids, 674 
Sphygmographic tracings, 570 
Spinal cord, diseases of, 707 

sclerosis of, tabes, 712 

haemorrhage, 728 

irritation, 760 . 
Spirals, asthma, 510 
Spirilla, 56 

of cholera, 336 
Spirochetes, 58 

of relapsing fever, 265, 267 
Spleen, enlargement of, in typhoid fever, 
292 

in anaemia, 610 

in leukaemia, 610 
Splenic fever, 81 
Spores, 59, 61 
Sporozoa, 66 
Spotted fever, 301 
Sputum, fluids for examination of, 538 

of abscess of lungs, 537 

of pneumonia, diplococcus of, 127 

of pneumonia, examination of, 135 

of tuberculosis, examination of, 61 
Staining fluids, 60 
Staphylococcus, 68 
Stenocardia, 585 
Stigmata, 611 

of hysteria, 769 
Stomach, catarrh of, 363 

cancer of, 359 

dilatation of, 385 

diseases of, 363 

diseases of, diet and treatment, 390 

neuralgia of, 387 

tube, 366, 369, 801 



INDEX. 



819 



Sternberg's diplococcus, 126 
Stone in "the kidney, 663 
Strangulation, intestinal, 401 
Strawberry tongue in scarlatina, 20S 
Streptococcus, 58 

curve, 799 

in diphtheria, 347, 850 

in erysipelas, 73 

in pyaemia, 69 

in quinsy, 258 

in tuberculosis, 147 
Stricture of intestine, 431 
Strychnia and tetanus. 109 
Subphrenic abscess. 553 
Subsulphate of iron in diphtheria, 251 
Succinic acid in echinococcus cysts, 37 
Succussion in the stomach, 385 
Sugar, in the blood, 598 

in the urine, 678 

in the urine, tests for, 679 
Sulphonal in urine, 805 
Sulphur in scabies, 5, 6 
Sulphuric acid, poisoning by, 796 
Summer catarrh, 122 
Sunstroke, 780 

Suprarenal capsules, disease of, 616 
Supra-orbital neuralgia, 292 
Sweating, as a sign of rickets, 630 

in rheumatism, 316 

in tuberculosis, 148 

of blood, 611 
Sweden, small-pox in, 236 
Sycosis, treatment of, 799 
Sylvester's method of artificial respira- 
tion, 532 
Syphilis, 169 

and cirrhosis of the liver, 465 

and vaccination, 238 

of the heart, 581 

of the kidney, 661 

of the larynx, 488 

of the liver, 470 

of the lungs, 539 

of the nose, 479 

of the pericardium, 563 

of the throat, 350 
Syphiloderm. 174 

Syphilides, pigmented, treatment of, 800 
Syringe, Koch's, for tuberculin, 491 
Syringomyelia, 729 

Tabes dorsalis, 711 
Tachycardia, 582, 583, 584 

in Basedow's disease, 586 
Taenia, 23 

armata, 27 

echinococcus, 34, 35 

lata. 29 

saginata, 24, 27 
Tamiaphobia, 33 
Tapeworm, 23 

as cause of pernicious anoemia, 803 

treatment of, 32 
Tarry stools, 415 
Teeth in hereditary syphilis, 171 



Teeth, notched, 350 

powder for, 354 

wash for preservation of, 615 
Temperature charts, in malaria, 291 

in measles, 193 

in measles and scarlet fever, 194 

in pneumonia, 129 

in scarlet fever, 205 

in typhoid fever, 271, 277, 278 

in typhus fever, 262 

in variola, 222 

in yellow fever, 298 
Test, for acetone in diabetes, 681 

for cocaine, 793 

for sus;ar in the urine, 679 

Teichmann's, for blood, 382, 416 

uric acid, murexide, 663 
Testicle, in mumps, 188 

inoculated, as test for glanders, 96 

juice, injection of, 765 
Tetanotoxine, 64, 107 
Tetanus, 105 

and cerebro-spinal meningitis, 310 

and strychnia poisoning, 109 

and tetany, 109, 734 
Tetany, 733 
Thirst in diabetes, 680 
Thomsen's disease, 691 
Threadworm, 41 
Throat, syphilis of, 350 
Thrombus of pulmonary arteries, 534 
Thrush, 15 
Thymol, in favus, 12 

in preservation of teeth, 615 

in round worm, treatment of. 41 

in trichinosis, treatment of, 52 
Thyroid gland, affection of, in Base- 
dow's disease, 587 

gland, disease of, 802 
Tic douloureux, 686 
Tinea favosa, 9 
Tizzoni and Centanni on hydrophobia, 

105 
Tobacco, poisoning by, 795 

heart, 583 
Toe, big, affection of, in gout, 625 
Tongue, black, 356 

condition of, 349, 354 

thrush of, 16 
Tonsillitis, 257, 356 

and diphtheria, 250 
Tonsils, hypertrophy of, 357 

stomata of, 350 
Tophi of gout, 621 
Toxalbumins, 64 
Toxine, of cholera, 337 

of diphtheria, 247 

of measles. 199 

of pertussis, 113 

of scarlatina, 205 

of tetanus, 107 

of typhoid fever, 64 
Toxines, 63 

Tracheotomy in croup, 256 
Transfusion in dysentery, 335 



820 



INDEX. 



Transfusion, in haemorrhage of the bow- 
els, 412 

of blood, 798 

of salt solution, 343 
Tremor, of alcoholism, 789 

of delirium tremens, 790 

of dementia paralytica, 776 

of multiple sclerosis, 772 

of paralysis agitans, 772 
Trematoid worms, 54 
Trichina spiralis, 45, 322 
Trichinosis, 45 
Trichloracetic acid, 481 
Trichomonas intestinalis, 400 
x Trichocephalus dispar, 44 
Trichophyton tonsurans, 12 
Tricuspid valve, insufficiency, 575 

obstruction, 576 
Trigeminus, neuralgia of, 686 
Trismus, 105 

Trommer's test for sugar, 679 
Tubercle bacillus, 62 

culture, 62 

in blood, 601 

staining fluid, 61 
Tuberculin, 151, 158 
Tuberculosis, 137 

acute miliary, 164 

and amyloid degeneration, 659 

and bronchiectasis, 501 

and diabetes, 681 

and glanders, 95 

and influenza, 120 

and measles, 195 

and pericarditis, 557, 562 

and pneumonia, diagnosis, 135 

and sepsis, 71 

and vaccination, 238 

as cause of bronchitis, 491 

of the bladder, 671 

of the bones and joints, 165 

of the brain, 159, 750 

of the genito-urinary apparatus, 164 

of the heart, 581 

of the kidney, 660 

of the larynx, 149, 486, 802 

of the lymph glands, 164 
Tuberculous meningitis, 159 

tumor of the brain, 750 

ulcer of intestine, 405 
Tumor, of the brain, 750 

in cancer of the stomach, 383 
Turpentine in tapeworms, 33 
Typhlitis, 417 
Typhoid bacillus, 269 

cholera, 338 

fever, 268 

fever and cerebro-spinal meningitis, 
310 

fever and dysentery, 320 

fever and pneumonia, diagnosis, 134 

fever and septicaemia. 70 

fever and variola, 229 

fever, perforation of intestine in, 801 
Typhotoxine, 64, 271 



Typhus abdominalis, 268 
exanthematicus, 259 
fever, 258, 259, 268 
fever and variola, 229 

Uffelmann's test for lactic acid, 369 
Ulcer, dysenteric, 328, 334 

of the intestine, 403 

of the stomach, 372 

of the stomach and gall stones, diag- 
nosis, 452 

perforating, of foot, 690 

tuberculous, of the larynx, 149 

tuberculous, of the intestine, 148 
Uraemia, 641, 655 

in yellow fever, 299 
Urea, estimate of quantity, 642 

in blood, 599 
Urethra, epithelium of, in urine, 649 
Urethritis, posterior, 181 
Uric acid in blood in gout, examination 
of, 622 

acid in gout, 618, 622 

acid in infarction in new-born, 665 

acid in kidney stones, 663 
Urinary system, diseases of, 637 
Urine, bacillus tuberculosis in, 164 

blood corpuscles in, 665 

gonorrhceal threads in, 184 

in cirrhosis hepatis, 468 

in hysteria, 761 

incontinence of, 672, 805 

sugar in, 678 

sugar in, tests for. 679 

test for bile in, 441 
Uvula, deviation of, in facial paralysis, 
695 

Vaccination, 233 

followed by pericarditis, 558 

in the treatment of variola, 232 

syphilis, 238 
Valvular fold of appendix vermiformis, 

420 
Varicella, 240 

and variola, diagnosis, 243 
Variola, 218 
Varioloid, 225 
Vaso motor neurosis, Raynaud's disease, 

730 
Vegetable parasites, ectozoa, 9 
Vegetations, verrucose, on valves of 

heart, 565 
Vein, femoral, obliterated, 596 
Veins, disease of, phlebitis, 595 
Ventilation, defective, cause of bronchi- 
tis, 503 
Ventricle, heart, hypertrophy of, 574 

heart, hypertrophy of, in nephritis, 
642, 655 
Vertebral caries, 165, 167 
Vicarious emphysema. 519 

menstruation, 761 
Vienna, small-pox in, 236 
Vision, affection of, in endocarditis, 568 






INDEX. 



821 



Voice, piping, of paralysis agitans, 771 

Volvulus, 429, 431 

Vomit, black, 296 

Vomited matter in cancer of stomach, 386 

Vomiting, in intestinal occlusion, 433 

in stomach disease, 392 

treatment of, 396 
Vomito negro, 296 

Wasp, sting of, 9 

Wasting palsy, 719 

Water, necessity of, in dietary, 392 

purification in prophylaxis of ty- 
phoid fever, 279 
Weil's disease. 474 
Whipworm, 44 

Whisper, audible, as test of effusion in 
pleurisy, 546 



Whooping cough, 112 

mortality of, 804 
White blood corpuscles, variations of, 600 
Wine whey, preparation of, 393 
Worms, intestinal, 23 
Wrist drop, in lead poisoning, 787 

in neuritis, 691 
Writer's cramp, 778 
Writing hand in paralysis agitans, 771 

Yeast plant, 3, 58 
Yellow fever, 296 

Ziehl-Keelsen solution, 60 

Zinc lactate in epilepsy, 750 

Zoogloea, 56 

Zwieback in dietary, 394 

Zyrooplastic matter in haemophilia, 614 



D 



3/9 ffa 



